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Please specify in full.\",\"type\":\"control_textbox\"}]);}, 20); \n<\/script>\n<\/head>\n<body>\n<form class=\"jotform-form\" action=\"https:\/\/submit.jotform.co\/submit\/72147470159862\/\" method=\"post\" name=\"form_72147470159862\" id=\"72147470159862\" accept-charset=\"utf-8\" autocomplete=\"on\">\n  <input type=\"hidden\" name=\"formID\" value=\"72147470159862\" \/>\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_dropdown\" id=\"id_47\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_47\" for=\"input_47\">\n          What programme would you like to enrol your child for? \u00a0\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_47\" class=\"form-input-wide jf-required\">\n          <select class=\"form-dropdown validate[required]\" id=\"input_47\" name=\"q47_whatProgramme47\" style=\"width:150px\" data-component=\"dropdown\" required=\"\" aria-labelledby=\"label_47\">\n            <option value=\"\">  <\/option>\n            <option value=\"Breakfast Club ONLY\"> Breakfast Club ONLY <\/option>\n            <option value=\"After School Care ONLY\"> After School Care ONLY <\/option>\n            <option value=\"Breakfast Club &amp; After School Care\"> Breakfast Club &amp; After School Care <\/option>\n          <\/select>\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\" required=\"\" \/>\n              <label id=\"label_input_32_0\" for=\"input_32_0\"> Yes <\/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          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_childsName[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_childsName[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          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_childsDob[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_childsDob[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_childsDob[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          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_gender\" 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 jf-required\" data-type=\"control_textbox\" id=\"id_49\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_49\" for=\"input_49\">\n          School child attends\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_49\" class=\"form-input-wide jf-required\">\n          <input type=\"text\" id=\"input_49\" name=\"q49_schoolChild\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" size=\"20\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_49\" required=\"\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_address\" id=\"id_48\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_48\" for=\"input_48_addr_line1\">\n          Child's Address\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_48\" 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_48_addr_line1\" name=\"q48_childsAddress[addr_line1]\" class=\"form-textbox validate[required] form-address-line\" value=\"\" data-component=\"address_line_1\" aria-labelledby=\"label_48 sublabel_48_addr_line1\" \/>\n                  <label class=\"form-sub-label\" for=\"input_48_addr_line1\" id=\"sublabel_48_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\" style=\"display:none\">\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_48_addr_line2\" name=\"q48_childsAddress[addr_line2]\" class=\"form-textbox form-address-line\" value=\"\" data-component=\"address_line_2\" aria-labelledby=\"label_48 sublabel_48_addr_line2\" \/>\n                  <label class=\"form-sub-label\" for=\"input_48_addr_line2\" id=\"sublabel_48_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_48_city\" name=\"q48_childsAddress[city]\" class=\"form-textbox validate[required] form-address-city\" value=\"\" data-component=\"city\" aria-labelledby=\"label_48 sublabel_48_city\" \/>\n                  <label class=\"form-sub-label\" for=\"input_48_city\" id=\"sublabel_48_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 form-address-hiddenLine\" style=\"display:none\">\n                <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n                  <input type=\"text\" id=\"input_48_state\" name=\"q48_childsAddress[state]\" class=\"form-textbox validate[required] form-address-state\" value=\"\" data-component=\"state\" aria-labelledby=\"label_48 sublabel_48_state\" \/>\n                  <label class=\"form-sub-label\" for=\"input_48_state\" id=\"sublabel_48_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_48_postal\" name=\"q48_childsAddress[postal]\" class=\"form-textbox form-address-postal\" value=\"\" data-component=\"zip\" aria-labelledby=\"label_48 sublabel_48_postal\" \/>\n                  <label class=\"form-sub-label\" for=\"input_48_postal\" id=\"sublabel_48_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 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              Parent&#x27;s 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_74\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_74\" for=\"input_74\">\n          Relationship to the child\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_74\" class=\"form-input-wide jf-required\">\n          <input type=\"text\" id=\"input_74\" name=\"q74_relationshipTo74\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" size=\"20\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_74\" required=\"\" \/>\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 jf-required\" 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\">\n          Alternative Phone Number\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_21\" 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_21_area\" name=\"q21_alternativePhone[area]\" class=\"form-textbox validate[required]\" value=\"\" data-component=\"areaCode\" aria-labelledby=\"label_21 sublabel_21_area\" required=\"\" \/>\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 validate[required]\" value=\"\" data-component=\"phone\" aria-labelledby=\"label_21 sublabel_21_phone\" required=\"\" \/>\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_fullname\" id=\"id_50\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_50\" for=\"first_50\">\n          Secondary Contact Name\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_50\" 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_50\" name=\"q50_secondaryContact[first]\" class=\"form-textbox validate[required]\" size=\"10\" value=\"\" data-component=\"first\" aria-labelledby=\"label_50 sublabel_50_first\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"first_50\" id=\"sublabel_50_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_50\" name=\"q50_secondaryContact[last]\" class=\"form-textbox validate[required]\" size=\"15\" value=\"\" data-component=\"last\" aria-labelledby=\"label_50 sublabel_50_last\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"last_50\" id=\"sublabel_50_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_75\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_75\" for=\"input_75\">\n          Relationship to the child\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_75\" class=\"form-input-wide jf-required\">\n          <input type=\"text\" id=\"input_75\" name=\"q75_relationshipTo75\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" size=\"20\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_75\" required=\"\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_phone\" id=\"id_51\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_51\" for=\"input_51_area\">\n          Phone Number\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_51\" 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_51_area\" name=\"q51_phoneNumber[area]\" class=\"form-textbox validate[required]\" value=\"\" data-component=\"areaCode\" aria-labelledby=\"label_51 sublabel_51_area\" required=\"\" \/>\n              <span class=\"phone-separate\" aria-hidden=\"true\">\n                \u00a0-\n              <\/span>\n              <label class=\"form-sub-label\" for=\"input_51_area\" id=\"sublabel_51_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_51_phone\" name=\"q51_phoneNumber[phone]\" class=\"form-textbox validate[required]\" value=\"\" data-component=\"phone\" aria-labelledby=\"label_51 sublabel_51_phone\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"input_51_phone\" id=\"sublabel_51_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_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\" 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\"> Home Address (if same as the child leave in blank) <\/label>\n        <div id=\"cid_22\" class=\"form-input-wide\">\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_homeAddress22[addr_line1]\" class=\"form-textbox 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_homeAddress22[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_homeAddress22[city]\" class=\"form-textbox 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_homeAddress22[state]\" class=\"form-textbox 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_homeAddress22[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 id=\"cid_52\" 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_52\" class=\"form-header\" data-component=\"header\">\n              Child&#x27;s Information\n            <\/h2>\n          <\/div>\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 jf-required\" 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\">\n          Doctor's Phone Number\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_29\" 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_29_area\" name=\"q29_doctorsPhone[area]\" class=\"form-textbox validate[required]\" value=\"\" data-component=\"areaCode\" aria-labelledby=\"label_29 sublabel_29_area\" required=\"\" \/>\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 validate[required]\" value=\"\" data-component=\"phone\" aria-labelledby=\"label_29 sublabel_29_phone\" required=\"\" \/>\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 class=\"form-line jf-required\" data-type=\"control_radio\" id=\"id_61\">\n        <label class=\"form-label form-label-left\" id=\"label_61\" for=\"input_61\">\n          Authorization\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_61\" class=\"form-input jf-required\">\n          <div class=\"form-single-column\" role=\"group\" aria-labelledby=\"label_61\" 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_61_0\" name=\"q61_authorization\" value=\"I give authorization for The SMASH Club staff to seek medical treatment for my child in case of emergency, and I agree to cover any cost incurred.\" required=\"\" \/>\n              <label id=\"label_input_61_0\" for=\"input_61_0\"> I give authorization for The SMASH Club staff to seek medical treatment for my child in case of emergency, and I agree to cover any cost incurred. <\/label>\n            <\/span>\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 need to be aware of? Please specify in full.\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_doesYour26\" 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_76\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_76\" for=\"input_76\">\n          Does your child have any behavioral need that we need to be aware of? Please specify in full.\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_76\" class=\"form-input-wide jf-required\">\n          <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n            <input type=\"text\" id=\"input_76\" name=\"q76_doesYour\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" size=\"20\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_76 sublabel_input_76\" required=\"\" \/>\n            <label class=\"form-sub-label\" for=\"input_76\" id=\"sublabel_input_76\" 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_77\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_77\" for=\"input_77\">\n          Are there any cultural customs or practices that the child has\/does that SMASH should be aware of? Please specify in full.\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_77\" class=\"form-input-wide jf-required\">\n          <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n            <input type=\"text\" id=\"input_77\" name=\"q77_areThere77\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" size=\"20\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_77 sublabel_input_77\" required=\"\" \/>\n            <label class=\"form-sub-label\" for=\"input_77\" id=\"sublabel_input_77\" 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_checkbox\" id=\"id_23\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_23\" for=\"input_23\">\n          Tick the days you would like your child to attend SMASH. Please note this is ONLY an indication of your preference, and does not guarantee you a place.\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_23\" class=\"form-input-wide jf-required\">\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 validate[required]\" id=\"input_23_0\" name=\"q23_tickThe23[]\" value=\"Monday\" required=\"\" \/>\n              <label id=\"label_input_23_0\" for=\"input_23_0\"> Monday <\/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 validate[required]\" id=\"input_23_1\" name=\"q23_tickThe23[]\" value=\"Tuesday\" required=\"\" \/>\n              <label id=\"label_input_23_1\" for=\"input_23_1\"> Tuesday <\/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 validate[required]\" id=\"input_23_2\" name=\"q23_tickThe23[]\" value=\"Wednesday\" required=\"\" \/>\n              <label id=\"label_input_23_2\" for=\"input_23_2\"> Wednesday <\/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 validate[required]\" id=\"input_23_3\" name=\"q23_tickThe23[]\" value=\"Thursday\" required=\"\" \/>\n              <label id=\"label_input_23_3\" for=\"input_23_3\"> Thursday <\/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 validate[required]\" id=\"input_23_4\" name=\"q23_tickThe23[]\" value=\"Friday\" required=\"\" \/>\n              <label id=\"label_input_23_4\" for=\"input_23_4\"> Friday <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_datetime\" id=\"id_53\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_53\" for=\"lite_mode_53\">\n          What is your preferred STARTING date?\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_53\" class=\"form-input-wide jf-required\">\n          <div data-wrapper-react=\"true\">\n            <div style=\"display:none\">\n              <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n                <input type=\"tel\" class=\"form-textbox validate[required, limitDate]\" id=\"day_53\" name=\"q53_whatIs[day]\" size=\"2\" data-maxlength=\"2\" data-age=\"\" maxLength=\"2\" value=\"\" required=\"\" autoComplete=\"off\" aria-labelledby=\"label_53 sublabel_53_day\" \/>\n                <span class=\"date-separate\" aria-hidden=\"true\">\n                  \u00a0-\n                <\/span>\n                <label class=\"form-sub-label\" for=\"day_53\" id=\"sublabel_53_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_53\" name=\"q53_whatIs[month]\" size=\"2\" data-maxlength=\"2\" data-age=\"\" maxLength=\"2\" value=\"\" required=\"\" autoComplete=\"off\" aria-labelledby=\"label_53 sublabel_53_month\" \/>\n                <span class=\"date-separate\" aria-hidden=\"true\">\n                  \u00a0-\n                <\/span>\n                <label class=\"form-sub-label\" for=\"month_53\" id=\"sublabel_53_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_53\" name=\"q53_whatIs[year]\" size=\"4\" data-maxlength=\"4\" data-age=\"\" maxLength=\"4\" value=\"\" required=\"\" autoComplete=\"off\" aria-labelledby=\"label_53 sublabel_53_year\" \/>\n                <label class=\"form-sub-label\" for=\"year_53\" id=\"sublabel_53_year\" style=\"min-height:13px\" aria-hidden=\"false\"> Year <\/label>\n              <\/span>\n            <\/div>\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n              <input type=\"text\" class=\"form-textbox validate[required, limitDate, validateLiteDate]\" id=\"lite_mode_53\" size=\"12\" data-maxlength=\"12\" maxLength=\"12\" data-age=\"\" value=\"\" required=\"\" data-format=\"ddmmyyyy\" data-seperator=\"-\" placeholder=\"dd-mm-yyyy\" autoComplete=\"off\" aria-labelledby=\"label_53 sublabel_53_litemode\" \/>\n              <img class=\" newDefaultTheme-dateIcon icon-liteMode\" alt=\"Pick a Date\" id=\"input_53_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=\"lite_mode_53\" id=\"sublabel_53_litemode\" style=\"min-height:13px\" aria-hidden=\"false\"> Date <\/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          We would like to know the reason why you require before or\/and after school care, please!\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_weWould54\" 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_radio\" id=\"id_62\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_62\" for=\"input_62\">\n          Are there any custody arrangements that we should know about?\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_62\" class=\"form-input-wide jf-required\">\n          <div class=\"form-multiple-column\" data-columncount=\"2\" role=\"group\" aria-labelledby=\"label_62\" 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_62_0\" name=\"q62_areThere\" value=\"Yes\" required=\"\" \/>\n              <label id=\"label_input_62_0\" for=\"input_62_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_62_1\" name=\"q62_areThere\" value=\"No\" required=\"\" \/>\n              <label id=\"label_input_62_1\" for=\"input_62_1\"> No <\/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 id=\"subHeader_31\" class=\"form-subHeader\">\n              Note, the emergency contact person must be allowed to collect your child in an emergency.\n            <\/div>\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 #1 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_emergencyContact33[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_emergencyContact33[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 #1 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_emergencyContact[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_emergencyContact[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 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          Relationship to the child:\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_57\" class=\"form-input-wide jf-required\">\n          <input type=\"text\" id=\"input_57\" name=\"q57_relationshipTo57\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" size=\"20\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_57\" required=\"\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_fullname\" id=\"id_55\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_55\" for=\"first_55\">\n          Emergency Contact #2 Name\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_55\" 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_55\" name=\"q55_emergencyContact55[first]\" class=\"form-textbox validate[required]\" size=\"10\" value=\"\" data-component=\"first\" aria-labelledby=\"label_55 sublabel_55_first\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"first_55\" id=\"sublabel_55_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_55\" name=\"q55_emergencyContact55[last]\" class=\"form-textbox validate[required]\" size=\"15\" value=\"\" data-component=\"last\" aria-labelledby=\"label_55 sublabel_55_last\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"last_55\" id=\"sublabel_55_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_56\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_56\" for=\"input_56_area\">\n          Emergency Contact #2 Phone Number\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_56\" 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_56_area\" name=\"q56_emergencyContact56[area]\" class=\"form-textbox validate[required]\" value=\"\" data-component=\"areaCode\" aria-labelledby=\"label_56 sublabel_56_area\" required=\"\" \/>\n              <span class=\"phone-separate\" aria-hidden=\"true\">\n                \u00a0-\n              <\/span>\n              <label class=\"form-sub-label\" for=\"input_56_area\" id=\"sublabel_56_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_56_phone\" name=\"q56_emergencyContact56[phone]\" class=\"form-textbox validate[required]\" value=\"\" data-component=\"phone\" aria-labelledby=\"label_56 sublabel_56_phone\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"input_56_phone\" id=\"sublabel_56_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_textbox\" id=\"id_58\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_58\" for=\"input_58\">\n          Relationship to the child:\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_58\" class=\"form-input-wide jf-required\">\n          <input type=\"text\" id=\"input_58\" name=\"q58_relationshipTo\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" size=\"20\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_58\" required=\"\" \/>\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_73\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_73\" for=\"input_73\">\n          I understand that The SMASH Club is part of St Mary's Ministries and offers programmes with Christian content, and I agree that I will liaise with my child if I don't agree with them attending it.\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_73\" class=\"form-input-wide jf-required\">\n          <div class=\"form-multiple-column\" data-columncount=\"2\" role=\"group\" aria-labelledby=\"label_73\" 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_73_0\" name=\"q73_iUnderstand73\" value=\"Yes\" required=\"\" \/>\n              <label id=\"label_input_73_0\" for=\"input_73_0\"> Yes <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_radio\" id=\"id_72\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_72\" for=\"input_72\">\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_72\" class=\"form-input-wide jf-required\">\n          <div class=\"form-multiple-column\" data-columncount=\"2\" role=\"group\" aria-labelledby=\"label_72\" 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_72_0\" name=\"q72_iUnderstand72\" value=\"Yes\" required=\"\" \/>\n              <label id=\"label_input_72_0\" for=\"input_72_0\"> Yes <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_radio\" id=\"id_71\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_71\" for=\"input_71\">\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_71\" class=\"form-input-wide jf-required\">\n          <div class=\"form-multiple-column\" data-columncount=\"2\" role=\"group\" aria-labelledby=\"label_71\" 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_71_0\" name=\"q71_iGive\" value=\"Yes\" required=\"\" \/>\n              <label id=\"label_input_71_0\" for=\"input_71_0\"> Yes <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_radio\" id=\"id_69\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_69\" for=\"input_69\">\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_69\" class=\"form-input-wide jf-required\">\n          <div class=\"form-multiple-column\" data-columncount=\"2\" role=\"group\" aria-labelledby=\"label_69\" 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_69_0\" name=\"q69_sunScreen\" value=\"Yes\" required=\"\" \/>\n              <label id=\"label_input_69_0\" for=\"input_69_0\"> Yes <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_radio\" id=\"id_70\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_70\" for=\"input_70\">\n          Do you authorize The Smash Club\u00a0to take pictures of your child and use it in our website and\/or promotional materials?\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_70\" class=\"form-input-wide jf-required\">\n          <div class=\"form-multiple-column\" data-columncount=\"2\" role=\"group\" aria-labelledby=\"label_70\" 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_70_0\" name=\"q70_doYou70\" value=\"Yes\" required=\"\" \/>\n              <label id=\"label_input_70_0\" for=\"input_70_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_70_1\" name=\"q70_doYou70\" value=\"No\" required=\"\" \/>\n              <label id=\"label_input_70_1\" for=\"input_70_1\"> No <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_radio\" id=\"id_67\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_67\" for=\"input_67\">\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_67\" class=\"form-input-wide jf-required\">\n          <div class=\"form-multiple-column\" data-columncount=\"2\" role=\"group\" aria-labelledby=\"label_67\" 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_67_0\" name=\"q67_paracetamol67\" value=\"Yes\" required=\"\" \/>\n              <label id=\"label_input_67_0\" for=\"input_67_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_67_1\" name=\"q67_paracetamol67\" value=\"No\" required=\"\" \/>\n              <label id=\"label_input_67_1\" for=\"input_67_1\"> No <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_radio\" id=\"id_68\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_68\" for=\"input_68\">\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_68\" class=\"form-input-wide jf-required\">\n          <div class=\"form-multiple-column\" data-columncount=\"2\" role=\"group\" aria-labelledby=\"label_68\" 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_68_0\" name=\"q68_arnica\" value=\"Yes\" required=\"\" \/>\n              <label id=\"label_input_68_0\" for=\"input_68_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_68_1\" name=\"q68_arnica\" value=\"No\" required=\"\" \/>\n              <label id=\"label_input_68_1\" for=\"input_68_1\"> No <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li id=\"cid_64\" 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_64\" class=\"form-header\" data-component=\"header\">\n              Administering Medication Consent\n            <\/h2>\n            <div id=\"subHeader_64\" class=\"form-subHeader\">\n              For long term medication only\n            <\/div>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_63\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_63\" for=\"input_63\"> Medication Name <\/label>\n        <div id=\"cid_63\" class=\"form-input-wide\">\n          <input type=\"text\" id=\"input_63\" name=\"q63_medicationName\" data-type=\"input-textbox\" class=\"form-textbox\" size=\"20\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_63\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_65\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_65\" for=\"input_65\"> Dosage <\/label>\n        <div id=\"cid_65\" class=\"form-input-wide\">\n          <input type=\"text\" id=\"input_65\" name=\"q65_dosage\" data-type=\"input-textbox\" class=\"form-textbox\" size=\"20\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_65\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_66\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_66\" for=\"input_66\"> When to administer <\/label>\n        <div id=\"cid_66\" class=\"form-input-wide\">\n          <input type=\"text\" id=\"input_66\" name=\"q66_whenTo\" data-type=\"input-textbox\" class=\"form-textbox\" size=\"20\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_66\" \/>\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. Only authorised staff will have access to that information. If we are concerned about your child's safety and believe that sharing this information with key agencies will protect your child, we are allowed, buy law, to do so. 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 withing taht 5 year period.<\/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\/terms-conditions\/\" target=\"_blank\" rel=\"nofollow\">After School Care 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>I will sign my child IN (Breakfast Club) and OUT (After School Care).<\/p>\n            <p>The SMASH Club staff\u00a0have my permission to arrange any necessary urgent medical treatment at my cost.<\/p>\n            <p>I will notify the office\u00a0of any changes to current enrolment information in a timely fashion.<\/p>\n            <p>I agree to pay fees as stipulated in the fees policy.<\/p>\n            <p>I understand the LATE CANCELLATION FEES - 2 weeks' notice for After School Care and 1 week for Breakfast Club<\/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          Finally, it is very important to us 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_finallyIt\" 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=\"72147470159862\" \/>\n  <script type=\"text\/javascript\">\n  var all_spc = document.querySelectorAll(\"form[id='72147470159862'] .si\" + \"mple\" + \"_spc\");\nfor (var i = 0; i < all_spc.length; i++)\n{\n  all_spc[i].value = \"72147470159862-72147470159862\";\n}\n  <\/script>\n<\/form><\/body>\n<\/html>\n","Breakfast Club &amp; After School Enrolment Form",Array);(function(){window.handleIFrameMessage=function(e){if(!e.data||!e.data.split)return;var args=e.data.split(":");if(args[2]!="72147470159862"){return;}
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