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Inspiring Jewish Pride and Identity in Jewish Children - the future of Judaism.
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<span style="background-color: transparent; font-family: Muli, sans-serif; color: rgb(0, 128, 128);">Thank you for choosing Chabad Russian Center of Thornhill Woods Hebrew School. We cannot wait to meet your child!</span></p>
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<span style="color: rgb(0, 128, 128);">At our Hebrew School we take pride in our low student/teacher ratio and strive to create a warm family Hebrew School experience. </span></p>
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<span style="color: rgb(0, 128, 128);">Please note that a parent meeting with Rabbi Chaim &amp; Chanie Hildeshaim will be required for all new students in advance of the new School year. Meeting will allow us to create an open line of communication so that we can understand your child’s personal needs, current level of Hebrew reading, unique learning style, and/or any concerns you may have. Getting to know you and your family will help ensure we understand your Hebrew School priorities and ensure your child will have the most positive and joyous Hebrew School experience. Please email </span><a href="mailto:Chanie@jewishtw.org">                       <span style="color: rgb(0, 128, 128);">Chanie@jewishtw.org</span></a><span style="color: rgb(0, 128, 128);"> after registering to book your meeting.  </span></p>
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<strong>Student Information</strong></span></p>
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<span style="color: rgb(0, 128, 128);"> </span></td>
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<span style="color: rgb(0, 128, 128);">Hebrew Name</span></p>
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<span style="color: rgb(0, 128, 128);"> </span></td>
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<input id="HebrewName" name="HebrewName" type="text"></span></p>
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<span style="color: rgb(0, 128, 128);">Gender</span></p>
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<span style="color: rgb(0, 128, 128);"> </span></td>
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<option value="Male">Male</option>
<option value="Female">Female</option>
<option value="Please Select" selected>Please Select</option>
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<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px; text-align: right;">
<span style="color: rgb(0, 128, 128);">Date of Birth</span></p>
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<span style="color: rgb(0, 128, 128);"> </span></td>
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<input id="DOB" required="true" name="DOB" type="text"></span></p>
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<span style="color: rgb(0, 128, 128);">Address</span></p>
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<span style="color: rgb(0, 128, 128);"> </span></td>
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<span style="color: rgb(0, 128, 128);">
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<span style="color: rgb(0, 128, 128);">City</span></p>
</td>
<td height="15" width="10%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<span style="color: rgb(0, 128, 128);"> </span></td>
<td height="15" width="40%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px;">
<span style="color: rgb(0, 128, 128);">
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</td>
</tr>
<tr>
<td height="15" width="50%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px; text-align: right;">
<span style="color: rgb(0, 128, 128);">Province</span></p>
</td>
<td height="15" width="10%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<span style="color: rgb(0, 128, 128);"> </span></td>
<td height="15" width="40%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px;">
<span style="color: rgb(0, 128, 128);">
<input id="State" name="State" value="ON" type="text"></span></p>
</td>
</tr>
<tr>
<td height="15" width="50%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px; text-align: right;">
<span style="color: rgb(0, 128, 128);">Postal</span></p>
</td>
<td height="15" width="10%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<span style="color: rgb(0, 128, 128);"> </span></td>
<td height="15" width="40%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px;">
<span style="color: rgb(0, 128, 128);">
<input id="Zip" required="true" name="Zip" type="text"></span></p>
</td>
</tr>
<tr>
<td height="15" width="50%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px; text-align: right;">
<span style="color: rgb(0, 128, 128);">Home Phone</span></p>
</td>
<td height="15" width="10%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<span style="color: rgb(0, 128, 128);"> </span></td>
<td height="15" width="40%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px;">
<span style="color: rgb(0, 128, 128);">
<input id="HomePhone" required="true" name="HomePhone" type="text"></span></p>
</td>
</tr>
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<td height="15" width="50%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
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<span id="lblSchool" style="color: rgb(0, 128, 128);">Previous School</span></p>
</td>
<td height="15" width="10%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<span style="color: rgb(0, 128, 128);"> </span></td>
<td height="15" width="40%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px;">
<span style="color: rgb(0, 128, 128);">
<input id="School" name="School" type="text"></span></p>
</td>
</tr>
<tr>
<td height="15" width="50%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px; text-align: right;">
<span id="lblNote" style="color: rgb(0, 128, 128);">Note</span></p>
</td>
<td height="15" width="10%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<span style="color: rgb(0, 128, 128);"> </span></td>
<td height="15" width="40%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px;">
<span style="color: rgb(0, 128, 128);">
<input id="Note" name="Note" type="text"></span></p>
</td>
</tr>
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<td height="15" width="50%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px;">
<span style="color: rgb(0, 128, 128);"> </span></p>
</td>
<td height="15" width="10%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<span style="color: rgb(0, 128, 128);"> </span></td>
<td height="15" width="40%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px;">
<span style="color: rgb(0, 128, 128);"> </span></p>
</td>
</tr>
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<td height="15" width="50%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px; text-align: right;">
<span style="color: rgb(0, 128, 128);">
<strong>Medical Information</strong></span></p>
</td>
<td height="15" width="10%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<span style="color: rgb(0, 128, 128);"> </span></td>
<td height="15" width="40%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px;">
<span style="color: rgb(0, 128, 128);"> </span></p>
</td>
</tr>
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<td height="15" width="50%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
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<span style="color: rgb(0, 128, 128);">Physician Name</span></p>
</td>
<td height="15" width="10%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<span style="color: rgb(0, 128, 128);"> </span></td>
<td height="15" width="40%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px;">
<span style="color: rgb(0, 128, 128);">
<input id="PhysicianName" required="true" name="PhysicianName" type="text"></span></p>
</td>
</tr>
<tr>
<td height="15" width="50%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px; text-align: right;">
<span style="color: rgb(0, 128, 128);">Physician Phone</span></p>
</td>
<td height="15" width="10%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<span style="color: rgb(0, 128, 128);"> </span></td>
<td height="15" width="40%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px;">
<span style="color: rgb(0, 128, 128);">
<input id="PhysicianPhone" required="true" name="PhysicianPhone" type="text"></span></p>
</td>
</tr>
<tr>
<td height="15" width="50%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px; text-align: right;">
<span id="lblInsurance" style="color: rgb(0, 128, 128);">Insurance</span></p>
</td>
<td height="15" width="10%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<span style="color: rgb(0, 128, 128);"> </span></td>
<td height="15" width="40%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px;">
<span style="color: rgb(0, 128, 128);">
<input id="Insurance" name="Insurance" type="text"></span></p>
</td>
</tr>
<tr>
<td height="15" width="50%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px; text-align: right;">
<span style="color: rgb(0, 128, 128);">Ohip Number</span></p>
</td>
<td height="15" width="10%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<span style="color: rgb(0, 128, 128);"> </span></td>
<td height="15" width="40%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px;">
<span style="color: rgb(0, 128, 128);">
<input id="InsuranceNo" required="true" name="InsuranceNo" type="text"></span></p>
</td>
</tr>
<tr>
<td height="15" width="50%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px; text-align: right;">
<span style="color: rgb(0, 128, 128);">Allergies</span></p>
</td>
<td height="15" width="10%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<span style="color: rgb(0, 128, 128);"> </span></td>
<td height="15" width="40%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px;">
<span style="color: rgb(0, 128, 128);">
<input id="Allergies" required="true" name="Allergies" type="text"></span></p>
</td>
</tr>
<tr>
<td height="15" width="50%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px; text-align: right;">
<span id="lblMedicalNote" style="color: rgb(0, 128, 128);">Medical Note</span></p>
</td>
<td height="15" width="10%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<span style="color: rgb(0, 128, 128);"> </span></td>
<td height="15" width="40%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px;">
<span style="color: rgb(0, 128, 128);">
<input id="MedicalNote" name="MedicalNote" type="text"></span></p>
</td>
</tr>
<tr>
<td height="15" width="50%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px;">
<span style="color: rgb(0, 128, 128);"> </span></p>
</td>
<td height="15" width="10%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<span style="color: rgb(0, 128, 128);"> </span></td>
<td height="15" width="40%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px;">
<span style="color: rgb(0, 128, 128);"> </span></p>
</td>
</tr>
<tr>
<td height="15" width="50%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px; text-align: right;">
<span style="color: rgb(0, 128, 128);">
<strong>Parent Information</strong></span></p>
</td>
<td height="15" width="10%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<span style="color: rgb(0, 128, 128);"> </span></td>
<td height="15" width="40%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px;">
<span style="color: rgb(0, 128, 128);"> </span></p>
</td>
</tr>
<tr>
<td height="15" width="50%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px; text-align: right;">
<span style="color: rgb(0, 128, 128);">
<strong>Father</strong></span></p>
</td>
<td height="15" width="10%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<span style="color: rgb(0, 128, 128);"> </span></td>
<td height="15" width="40%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px;">
<span style="color: rgb(0, 128, 128);"> </span></p>
</td>
</tr>
<tr>
<td height="15" width="50%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px; text-align: right;">
<span style="color: rgb(0, 128, 128);">Title</span></p>
</td>
<td height="15" width="10%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<span style="color: rgb(0, 128, 128);"> </span></td>
<td height="15" width="40%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px;">
<span style="color: rgb(0, 128, 128);">
<input id="HisFirstName" name="HisTitle" type="text"></span></p>
</td>
</tr>
<tr>
<td height="15" width="50%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px; text-align: right;">
<span style="color: rgb(0, 128, 128);">First Name</span></p>
</td>
<td height="15" width="10%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<span style="color: rgb(0, 128, 128);"> </span></td>
<td height="15" width="40%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px;">
<span style="color: rgb(0, 128, 128);">
<input id="HisFirstName" required="true" name="HisFirstName" type="text"></span></p>
</td>
</tr>
<tr>
<td height="15" width="50%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px; text-align: right;">
<span style="color: rgb(0, 128, 128);">Last Name</span></p>
</td>
<td height="15" width="10%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<span style="color: rgb(0, 128, 128);"> </span></td>
<td height="15" width="40%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px;">
<span style="color: rgb(0, 128, 128);">
<input id="HisLastName" required="true" name="HisLastName" type="text"></span></p>
</td>
</tr>
<tr>
<td height="15" width="50%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px; text-align: right;">
<span style="color: rgb(0, 128, 128);">Work Phone</span></p>
</td>
<td height="15" width="10%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<span style="color: rgb(0, 128, 128);"> </span></td>
<td height="15" width="40%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px;">
<span style="color: rgb(0, 128, 128);">
<input id="HisWorkPhone" name="HisWorkPhone" type="text"></span></p>
</td>
</tr>
<tr>
<td height="15" width="50%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px; text-align: right;">
<span style="color: rgb(0, 128, 128);">Cell Phone</span></p>
</td>
<td height="15" width="10%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<span style="color: rgb(0, 128, 128);"> </span></td>
<td height="15" width="40%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px;">
<span style="color: rgb(0, 128, 128);">
<input id="HisCellPhone" name="HisCellPhone" type="text"></span></p>
</td>
</tr>
<tr>
<td height="15" width="50%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px; text-align: right;">
<span style="color: rgb(0, 128, 128);">Email</span></p>
</td>
<td height="15" width="10%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<span style="color: rgb(0, 128, 128);"> </span></td>
<td height="15" width="40%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px;">
<span style="color: rgb(0, 128, 128);">
<input id="HisEmail" name="HisEmail" type="text"></span></p>
</td>
</tr>
<tr>
<td height="15" width="50%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px; text-align: right;">
<span style="color: rgb(0, 128, 128);"> </span></p>
</td>
<td height="15" width="10%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<span style="color: rgb(0, 128, 128);"> </span></td>
<td height="15" width="40%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px;">
<span style="color: rgb(0, 128, 128);"> </span></p>
</td>
</tr>
<tr>
<td height="15" width="50%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px; text-align: right;">
<span style="color: rgb(0, 128, 128);">
<strong>Mother</strong></span></p>
</td>
<td height="15" width="10%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<span style="color: rgb(0, 128, 128);"> </span></td>
<td height="15" width="40%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px;">
<span style="color: rgb(0, 128, 128);"> </span></p>
</td>
</tr>
<tr>
<td height="15" width="50%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<span style="color: rgb(0, 128, 128);"> </span></td>
<td height="15" width="10%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<span style="color: rgb(0, 128, 128);"> </span></td>
<td height="15" width="40%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px;">
<span style="color: rgb(0, 128, 128);">
<input id="HerFirstName" name="HerTitle" type="text"></span></p>
</td>
</tr>
<tr>
<td height="15" width="50%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px; text-align: right;">
<span id="lblHerFirstName" style="color: rgb(0, 128, 128);">First Name</span></p>
</td>
<td height="15" width="10%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<span style="color: rgb(0, 128, 128);"> </span></td>
<td height="15" width="40%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px;">
<span style="color: rgb(0, 128, 128);">
<input id="HerFirstName" required="true" name="HerFirstName" type="text"></span></p>
</td>
</tr>
<tr>
<td height="15" width="50%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px; text-align: right;">
<span id="lblHerLastName" style="color: rgb(0, 128, 128);">Last Name</span></p>
</td>
<td height="15" width="10%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<span style="color: rgb(0, 128, 128);"> </span></td>
<td height="15" width="40%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px;">
<span style="color: rgb(0, 128, 128);">
<input id="HerLastName" required="true" name="HerLastName" type="text"></span></p>
</td>
</tr>
<tr>
<td height="15" width="50%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px; text-align: right;">
<span id="lblHerWorkPhone" style="color: rgb(0, 128, 128);">Work Phone</span></p>
</td>
<td height="15" width="10%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<span style="color: rgb(0, 128, 128);"> </span></td>
<td height="15" width="40%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px;">
<span style="color: rgb(0, 128, 128);">
<input id="HerWorkPhone" name="HerWorkPhone" type="text"></span></p>
</td>
</tr>
<tr>
<td height="15" width="50%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px; text-align: right;">
<span style="color: rgb(0, 128, 128);">Cell Phone</span></p>
</td>
<td height="15" width="10%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<span style="color: rgb(0, 128, 128);"> </span></td>
<td height="15" width="40%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px;">
<span style="color: rgb(0, 128, 128);">
<input id="HerCellPhone" name="HerCellPhone" type="text"></span></p>
</td>
</tr>
<tr>
<td height="15" width="50%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px; text-align: right;">
<span style="color: rgb(0, 128, 128);">Email</span></p>
</td>
<td height="15" width="10%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<span style="color: rgb(0, 128, 128);"> </span></td>
<td height="15" width="40%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px;">
<span style="color: rgb(0, 128, 128);">
<input id="HerEmail" name="HerEmail" type="text"></span></p>
</td>
</tr>
<tr>
<td height="15" width="50%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px; text-align: right;">
<span style="color: rgb(0, 128, 128);">Marital Status</span></p>
</td>
<td height="15" width="10%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<span style="color: rgb(0, 128, 128);"> </span></td>
<td height="15" width="40%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px;">
<select tabindex="1" name="MaritalStatus">
<option value="Married">Married</option>
<option value="Seperated">Seperated</option>
<option value="Divorced">Divorced</option>
<option value="Please Select" selected>Please Select</option>
</select></p>
</td>
</tr>
<tr>
<td height="15" width="50%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px; text-align: right;">
<span style="color: rgb(0, 128, 128);"> </span></p>
</td>
<td height="15" width="10%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<span style="color: rgb(0, 128, 128);"> </span></td>
<td height="15" width="40%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<span style="color: rgb(0, 128, 128);"> </span></td>
</tr>
<tr>
<td height="15" width="50%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px; text-align: right;">
<span id="lblAdoptions" class="Small Checkbox" style="color: rgb(0, 128, 128);">Have there been adoptions or conversions in the family? <br>
                        If Yes, Please explain</span></p>
</td>
<td height="15" width="10%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<span style="color: rgb(0, 128, 128);"> </span></td>
<td height="15" width="40%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px;">
<select tabindex="1" name="Adoptions">
<option value="No">No</option>
<option value="Yes">Yes</option>
<option value="Please Select" selected>Please Select</option>
</select></p>
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px;">
<span style="color: rgb(0, 128, 128);">
<input type="text" name="Explanaing on Adoption in family" tabindex="1" required="false"></span></p>
</td>
</tr>
<tr>
<td height="15" width="50%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px; text-align: right;">
<span style="color: rgb(0, 128, 128);">Is mother Jewish from birth?</span><select name="MotherJewish" tabindex="1">
<option value="Yes">Yes</option>
<option value="Please Select" selected>Please Select</option>
<option value="No">No</option>
</select><span style="color: rgb(0, 128, 128);"><br>
                        Is Maternal Grandmother Jewish from birth? <br>
</span><select name="Grandmother Jewish" tabindex="1">
<option value="Please Select" selected>Please Select</option>
<option value="Yes">Yes</option>
<option value="No">No</option>
</select><span style="color: rgb(0, 128, 128);"><br>
                        If no to either of above questions, please explain:</span></p>
</td>
<td height="15" width="10%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<span style="color: rgb(0, 128, 128);"> </span></td>
<td height="15" width="40%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px;">
<span style="color: rgb(0, 128, 128);">
<input id="AdoptionNote" name="AdoptionNote" type="text"></span></p>
</td>
</tr>
<tr>
<td height="15" width="50%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px;">
<span style="color: rgb(0, 128, 128);"> </span></p>
</td>
<td height="15" width="10%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<span style="color: rgb(0, 128, 128);"> </span></td>
<td height="15" width="40%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px;">
<span style="color: rgb(0, 128, 128);"> </span></p>
</td>
</tr>
<tr>
<td height="15" width="50%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px; text-align: right;">
<span style="color: rgb(0, 128, 128);">
<strong>Emergency Information</strong></span></p>
</td>
<td height="15" width="10%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<span style="color: rgb(0, 128, 128);"> </span></td>
<td height="15" width="40%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px;">
<span style="color: rgb(0, 128, 128);"> </span></p>
</td>
</tr>
<tr>
<td height="15" width="50%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px; text-align: right;">
<span style="color: rgb(0, 128, 128);">Emergency 1</span></p>
</td>
<td height="15" width="10%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<span style="color: rgb(0, 128, 128);"> </span></td>
<td height="15" width="40%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px;">
<span style="color: rgb(0, 128, 128);">
<input id="Emer1Name" size="10" required="true" name="Emer1Name" value="Name" type="text"><input id="Emer1Phone" size="10" required="true" name="Emer1Phone" value="Phone #" type="text"><input id="Emer1Relation" size="10" required="true" name="Emer1Relation" value="Relation" type="text"></span></p>
</td>
</tr>
<tr>
<td height="15" width="50%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px; text-align: right;">
<span style="color: rgb(0, 128, 128);">Emergency 2</span></p>
</td>
<td height="15" width="10%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<span style="color: rgb(0, 128, 128);"> </span></td>
<td height="15" width="40%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px;">
<span style="color: rgb(0, 128, 128);">
<input id="Emer2Name" size="10" required="true" name="Emer2Name" value="Name" type="text"><input id="Emer2Phone" size="10" required="true" name="Emer2Phone" value="Phone #" type="text"><input id="Emer2Relation" size="10" required="true" name="Emer2Relation" value="Relation" type="text"></span></p>
</td>
</tr>
<tr>
<td height="15" width="50%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px; text-align: right;">
<span id="lblEmer3" style="color: rgb(0, 128, 128);">Emergency 3</span></p>
</td>
<td height="15" width="10%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<span style="color: rgb(0, 128, 128);"> </span></td>
<td height="15" width="40%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px;">
<span style="color: rgb(0, 128, 128);">
<input id="Emer3Name" size="10" name="Emer3Name" value="Name" type="text"><input id="Emer3Phone" size="10" name="Emer3Phone" value="Phone #" type="text"><input id="Emer3Relation" size="10" name="Emer3Relation" value="Relation" type="text"></span></p>
</td>
</tr>
<tr>
<td height="15" width="50%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px;">
<span style="color: rgb(0, 128, 128);"> </span></p>
</td>
<td height="15" width="10%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<span style="color: rgb(0, 128, 128);"> </span></td>
<td height="15" width="40%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px;">
<span style="color: rgb(0, 128, 128);"> </span></p>
</td>
</tr>
<tr>
<td height="15" width="50%" colspan="3" style="border: 1px dotted rgb(211, 211, 211);">
<div style="">
<span style="color: rgb(0, 128, 128);"><strong>Tuition &amp; Fees</strong><br>
                        September 2025-June 2026</span></div>
<div style="">
<span style="color: rgb(0, 128, 128);">Tuition:<br>
                        $800 + $100 registration &amp; book fee<br>
                        $100 off - Registration by August 18<br type="_moz">
</span></div>
<p>
<span style="color: rgb(0, 128, 128);"><strong>Discounts:</strong></span><span style="color: rgb(0, 128, 128);"></span></p>
<ul>
<li>
<span style="color: rgb(0, 128, 128);">$25 off for returning students</span></li>
<li>
<span style="color: rgb(0, 128, 128);">$25 off per child when singing up 2 or more siblings.</span></li>
<li>
<span style="color: rgb(0, 128, 128);">$25 off for referral to a new family.</span></li>
</ul>
</td>
</tr>
<tr>
<td height="15" width="50%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px; text-align: right;">
<span style="color: rgb(0, 128, 128);">Ages 5 - 12:</span></p>
</td>
<td height="15" width="10%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<span style="color: rgb(0, 128, 128);"> </span></td>
<td height="15" width="40%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px;">
<span style="color: rgb(0, 128, 128);"><input id="lSessions_1" type="checkbox" name="Sunday In person" value="on">Sunday 10:30 - 12:30 </span></p>
</td>
</tr>
<tr>
<td height="15" width="50%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px;">
<span style="color: rgb(0, 128, 128);">
<strong>Payment Information</strong></span></p>
</td>
<td height="15" width="10%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<span style="color: rgb(0, 128, 128);"> </span></td>
<td height="15" width="40%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px;">
<span style="color: rgb(0, 128, 128);"> </span></p>
</td>
</tr>
<tr>
<td height="15" width="50%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px; text-align: right;">
<span style="color: rgb(0, 128, 128);">Method of payment</span></p>
</td>
<td height="15" width="10%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<span style="color: rgb(0, 128, 128);"> </span></td>
<td height="15" width="40%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px;">
<select tabindex="1" name="Method of Payment">
<option value="Head Cheques">Head Cheques</option>
<option value="Credit Card">Credit Card</option>
<option value="Please Select" selected>Please Select</option>
</select></p>
</td>
</tr>
<tr>
<td height="15" width="50%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px; text-align: right;">
<span id="lblCardType" style="color: rgb(0, 128, 128);">Card Type</span></p>
</td>
<td height="15" width="10%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<span style="color: rgb(0, 128, 128);"> </span></td>
<td height="15" width="40%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px;">
<select tabindex="1" name="CardType">
<option value="Visa">Visa</option>
<option value="MasterCard">MasterCard</option>
<option value="Amex">Amex</option>
<option value="Please Select" selected>Please Select</option>
</select></p>
</td>
</tr>
<tr>
<td height="15" width="50%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px; text-align: right;">
<span id="lblCardNumber" style="color: rgb(0, 128, 128);">Card Number</span></p>
</td>
<td height="15" width="10%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<span style="color: rgb(0, 128, 128);"> </span></td>
<td height="15" width="40%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px;">
<span style="color: rgb(0, 128, 128);">
<input id="CardNumber" maxlength="16" required="true" name="CardNumber" type="text"></span></p>
</td>
</tr>
<tr>
<td height="15" width="50%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px; text-align: right;">
<span id="lblCardExpMonth" style="color: rgb(0, 128, 128);">Expiration Date</span></p>
</td>
<td height="15" width="10%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<span style="color: rgb(0, 128, 128);"> </span></td>
<td height="15" width="40%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px;">
<span style="color: rgb(0, 128, 128);">
<input id="CardNumber" name="Expry" value="mm/yyyy" type="text" required="false"></span></p>
</td>
</tr>
<tr>
<td height="15" width="50%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px; text-align: right;">
<span id="lblCardVV" style="color: rgb(0, 128, 128);">Security Code</span></p>
</td>
<td height="15" width="10%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<span style="color: rgb(0, 128, 128);"> </span></td>
<td height="15" width="40%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px;">
<span style="color: rgb(0, 128, 128);">
<input id="CardVV" maxlength="4" required="true" name="CardVV" type="text"></span></p>
</td>
</tr>
<tr>
<td height="15" width="50%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px; text-align: right;">
<span id="lblCardName" style="color: rgb(0, 128, 128);">Name on Card</span></p>
</td>
<td height="15" width="10%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<span style="color: rgb(0, 128, 128);"> </span></td>
<td height="15" width="40%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px;">
<span style="color: rgb(0, 128, 128);">
<input id="CardName" required="true" name="CardName" type="text"></span></p>
</td>
</tr>
<tr>
<td height="15" width="50%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px; text-align: right;">
<span id="lblCardAddress" style="color: rgb(0, 128, 128);">Billing Address</span></p>
</td>
<td height="15" width="10%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<span style="color: rgb(0, 128, 128);"> </span></td>
<td height="15" width="40%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px;">
<span style="color: rgb(0, 128, 128);">
<input id="CardAddress" required="true" name="CardAddress" type="text"></span></p>
</td>
</tr>
<tr>
<td height="15" width="50%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px; text-align: right;">
<span id="lblCardZip" style="color: rgb(0, 128, 128);">Billing Postal Code</span></p>
</td>
<td height="15" width="10%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<span style="color: rgb(0, 128, 128);"> </span></td>
<td height="15" width="40%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px;">
<span style="color: rgb(0, 128, 128);">
<input id="CardZip" required="true" name="CardZip" type="text"></span></p>
</td>
</tr>
<tr>
<td height="15" width="50%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px; text-align: right;">
<span style="color: rgb(0, 128, 128);"> </span></p>
</td>
<td height="15" width="10%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<span style="color: rgb(0, 128, 128);"> </span></td>
<td height="15" width="40%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px;">
<span style="color: rgb(0, 128, 128);">
<textarea tabindex="1" rows="3" cols="38" name="terms" style="height: 71px; width: 372px;"></textarea></span></p>
</td>
</tr>
<tr>
<td height="15" width="50%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px;">
<span style="color: rgb(0, 128, 128);"> </span></p>
</td>
<td height="15" width="10%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<span style="color: rgb(0, 128, 128);"> </span></td>
<td height="15" width="40%" style="font-family: Arial, Helvetica, sans-serif, 'MS sans serif'; border: 1px dotted rgb(211, 211, 211);">
<p class="SCHP_Text" style="font-family: Arial, Helvetica, sans-serif; font-size: 10pt; line-height: 24px;">
<span id="lblAgree" class="Small Checkbox" style="color: rgb(0, 128, 128);">I agree to the terms and conditions above</span></p>
</td>
</tr>
</tbody>
</table>
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</tr>
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