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	Simchas Torah Service Registration - Chabad Lubavitch of West Hampstead
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			<h1 class="article-header__title js-article-title js-page-title">Simchas Torah Service Registration</h1>
		
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        padding-top:12px;
        padding-bottom:12px;
    }
    .form-label-right{
        width:150px !important;
    }
    .form-all {
        font-size:14px;
    }
.co_body .content .form-all p {
 font-size:14px;

}
@media screen and (max-width: 600px) {.form-label-left{	float:none;	display:block;}.form-buttons-wrapper.button-align-auto{text-indent: 0!important;}}</style>

<form class="userform-form" action="" method="post" name="form_5218722" id="5218722" accept-charset="utf-8" data-stripe-index="47243900C6DE6D83" data-stripe-public-key="pk_live_51HCjWTAmzOl70sBzTyvInlfZL7MNtax7CHii5Fbjeju5VR6VxEKnuwk6feThBZb1NyJagMyj3XUvN1vpqXry879c00ejHjoYL4" data-stripe-connected-account="acct_1HCjWTAmzOl70sBz" data-stripe-platform-account="pk_live_51Gv897Gg4VIgh1AgJrNCTDA5O4gyuvK0hI9vIMRSjqhlGzT0aw7Dp7vGsHjGj1ajMt6jVYZiuAgGSuUw0lsJa84k00fjB3Qm4j">
  <input type="hidden" name="formID" value="5218722" />
  <div class="form-all dir_ltr" dir="ltr">
    <ul class="form-section">
      <li class="form-line" id="id_49">
        <div id="cid_49" class="form-input-wide">
          <img alt="" class="form-image" border="0" src="https://w2.chabad.org/media/images/1205/hBmF12057574.jpeg" height="700" width="600" />
        </div>
      </li>
      <li id="cid_6" class="form-input-wide">
        <div class="form-header-group">
          <h1 id="header_6" class="form-header">
            1. Your Infomation
          </h1>
        </div>
      </li>
      <li class="form-line" id="id_1">
        <div class="form-label-left" id="label_1">
          <label for="input_1">
            Full Name<span class="form-required">*</span>
          </label>
          <label class="label-message" for="input_1">  </label>
        </div>
        <div id="cid_1" class="form-input"><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q1_fullName1[first]" id="first_1" autocomplete="given-name" />
            <label class="form-sub-label" for="first_1" id="sublabel_first"> First Name </label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q1_fullName1[last]" id="last_1" autocomplete="family-name" />
            <label class="form-sub-label" for="last_1" id="sublabel_last"> Last Name </label></span>
        </div>
      </li>
      <li class="form-line" id="id_3">
        <div class="form-label-left" id="label_3">
          <label for="input_3">
            E-mail<span class="form-required">*</span>
          </label>
          <label class="label-message" for="input_3">  </label>
        </div>
        <div id="cid_3" class="form-input">
          <input type="email" class=" form-textbox validate[required, Email]" id="input_3" name="q3_email3" size="30" value="" autocomplete="email" />
        </div>
      </li>
      <li class="form-line" id="id_5">
        <div class="form-label-left" id="label_5">
          <label for="input_5">
            Phone Number<span class="form-required">*</span>
          </label>
          <label class="label-message" for="input_5">  </label>
        </div>
        <div id="cid_5" class="form-input">
          <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox validate[required, Numeric]" type="tel" name="q5_phoneNumber5[area]" id="input_5_area" autocomplete="tel-area-code" size="3" />
              <label class="form-sub-label" for="input_5_area" id="sublabel_area"> Area Code </label></span><span class="form-sub-label-container"><input class="form-textbox validate[required, Numeric]" type="tel" name="q5_phoneNumber5[phone]" id="input_5_phone" autocomplete="tel-local" size="8" />
              <label class="form-sub-label" for="input_5_phone" id="sublabel_phone"> Phone Number </label></span>
          </div>
        </div>
      </li>
      <li class="form-line" id="id_19">
        <div class="form-label-left" id="label_19">
          <label for="input_19"> Please, specify the names of the attendees. </label>
          <label class="label-message" for="input_19">  </label>
        </div>
        <div id="cid_19" class="form-input">
          <textarea id="input_19" class="form-textarea" name="q19_anyComments19" cols="40" rows="6"></textarea>
        </div>
      </li>
      <li id="cid_38" class="form-input-wide">
        <div class="form-header-group">
          <h1 id="header_38" class="form-header">
            2. Simchas Torah Night
          </h1>
        </div>
      </li>
      <li class="form-line" id="id_45">
        <div id="cid_45" class="form-input-wide">
          <div id="text_45" class="form-html">
            <p>
              The service will be on Sunday, October 16th at 6:00pm.
            </p>
            <p>
              The service will be followed by the Hakafot and a meaty buffet 
            </p>
          </div>
        </div>
      </li>
      <li class="form-line" id="id_26">
        <div class="form-label-left" id="label_26">
          <label for="input_26">
            Number of attendees<span class="form-required">*</span>
          </label>
          <label class="label-message" for="input_26">  </label>
        </div>
        <div id="cid_26" class="form-input">
          <select class="form-dropdown validate[required]" style="width:150px" id="input_26" name="q26_input26">
            <option value="">  </option>
            <option value="0"> 0 </option>
            <option value="1"> 1 </option>
            <option value="2"> 2 </option>
            <option value="3"> 3 </option>
            <option value="4"> 4 </option>
            <option value="5"> 5 </option>
            <option value="6"> 6 </option>
            <option value="7"> 7 </option>
            <option value="8"> 8 </option>
          </select>
        </div>
      </li>
      <li class="form-line" id="id_43">
        <div class="form-label-left" id="label_43">
          <label for="input_43"> Please, specify the names of the attendees. </label>
          <label class="label-message" for="input_43">  </label>
        </div>
        <div id="cid_43" class="form-input">
          <textarea id="input_43" class="form-textarea" name="q43_anyComments43" cols="40" rows="6"></textarea>
        </div>
      </li>
      <li id="cid_44" class="form-input-wide">
        <div class="form-header-group">
          <h1 id="header_44" class="form-header">
            3. Simchas Torah Day
          </h1>
        </div>
      </li>
      <li class="form-line" id="id_41">
        <div id="cid_41" class="form-input-wide">
          <div id="text_41" class="form-html">
            <p>
              The service will be on the morning of October 17th at 10:00am. 
            </p>
            <p>
              <b>
                Morning services will be followed by brunch, hakafot and a festive late lunch.
              </b>
            </p>
            <p>
              <b>
                <br />
              </b>
            </p>
            <p>
              <b>
                <br />
              </b>
            </p>
          </div>
        </div>
      </li>
      <li class="form-line" id="id_52">
        <div class="form-label-left" id="label_52">
          <label for="input_52">
            Number of attendees<span class="form-required">*</span>
          </label>
          <label class="label-message" for="input_52">  </label>
        </div>
        <div id="cid_52" class="form-input">
          <select class="form-dropdown validate[required]" style="width:150px" id="input_52" name="q52_input52">
            <option value="">  </option>
            <option value="0"> 0 </option>
            <option value="1"> 1 </option>
            <option value="2"> 2 </option>
            <option value="3"> 3 </option>
            <option value="4"> 4 </option>
            <option value="5"> 5 </option>
            <option value="6"> 6 </option>
            <option value="7"> 7 </option>
            <option value="8"> 8 </option>
          </select>
        </div>
      </li>
      <li class="form-line" id="id_53">
        <div class="form-label-left" id="label_53">
          <label for="input_53"> Please, specify the names of the attendees. </label>
          <label class="label-message" for="input_53">  </label>
        </div>
        <div id="cid_53" class="form-input">
          <textarea id="input_53" class="form-textarea" name="q53_anyComments53" cols="40" rows="6"></textarea>
        </div>
      </li>
      <li id="cid_50" class="form-input-wide">
        <div class="form-header-group">
          <h1 id="header_50" class="form-header">
            3. Simchas Torah Second Day
          </h1>
        </div>
      </li>
      <li class="form-line" id="id_51">
        <div id="cid_51" class="form-input-wide">
          <div id="text_51" class="form-html">
            <p>
              The service will be on the morning of October 18th at 10:00am. 
            </p>
            <p>
              <b>
                Morning services will be followed by brunch, hakafot and a festive late lunch.
              </b>
            </p>
            <p>
              <b>
                <br />
              </b>
            </p>
            <p>
              <b>
                <br />
              </b>
            </p>
          </div>
        </div>
      </li>
      <li class="form-line" id="id_46">
        <div class="form-label-left" id="label_46">
          <label for="input_46">
            Number of attendees<span class="form-required">*</span>
          </label>
          <label class="label-message" for="input_46">  </label>
        </div>
        <div id="cid_46" class="form-input">
          <select class="form-dropdown validate[required]" style="width:150px" id="input_46" name="q46_input46">
            <option value="">  </option>
            <option value="0"> 0 </option>
            <option value="1"> 1 </option>
            <option value="2"> 2 </option>
            <option value="3"> 3 </option>
            <option value="4"> 4 </option>
            <option value="5"> 5 </option>
            <option value="6"> 6 </option>
            <option value="7"> 7 </option>
            <option value="8"> 8 </option>
          </select>
        </div>
      </li>
      <li class="form-line" id="id_47">
        <div class="form-label-left" id="label_47">
          <label for="input_47"> Please, specify the names of the attendees. </label>
          <label class="label-message" for="input_47">  </label>
        </div>
        <div id="cid_47" class="form-input">
          <textarea id="input_47" class="form-textarea" name="q47_anyComments47" cols="40" rows="6"></textarea>
        </div>
      </li>
      <li id="cid_40" class="form-input-wide">
        <div class="form-header-group">
          <h1 id="header_40" class="form-header">
            4. Optional Donation
          </h1>
        </div>
      </li>
      <li class="form-line" id="id_32">
        <div id="cid_32" class="form-input-wide">
          <div id="text_32" class="form-html">
            <p>
              <em>
                Participation in all the Services for Simchas Torah are entirelly free.. Consider a donation to help cover the costs of these and other wonderful and vital programs that Chabad Jewish Center brings to our community.
              </em>
            </p>
            <p>
              <em>
                100% of the proceeds of this donation or payment benefit Chabad of West Hampstead. 
              </em>
            </p>
          </div>
        </div>
      </li>
      <li class="form-line" id="id_39">
        <div class="form-label-left" id="label_39">
          <label for="input_39">  </label>
          <label class="label-message" for="input_39">  </label>
        </div>
        <div id="cid_39" class="form-input">
          <div class="form-single-column" data-columns="0"><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_39_0" name="q39_input39" value="36" />
              <label for="input_39_0"><span>£36</span>
              </label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_39_1" name="q39_input39" value="72" />
              <label for="input_39_1"><span>£72</span>
              </label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_39_2" name="q39_input39" value="180" />
              <label for="input_39_2"><span>£180</span>
              </label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_39_3" name="q39_input39" value="360" />
              <label for="input_39_3"><span>£360</span>
              </label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio-other form-radio" name="q39_input39" id="other_39" value="" /><span><input type="number" min="1" class="form-radio-other-input form-textbox" onkeypress="validateNumber(event)" name="q39_input39[other]" data-otherhint="Other" size="15" id="input_39" disabled="disabled" /></span>
              <br /></span>
          </div>
        </div>
      </li>
      <li class="form-line" id="id_33">
        <div class="form-label-left" id="label_33">
          <label for="input_33">
            Payment<span class="form-required">*</span>
          </label>
          <label class="label-message" for="input_33">  </label>
        </div>
        <div id="cid_33" class="form-input">
          <table summary="" class="form-address-table" border="0" cellpadding="0" cellspacing="0">
            <tbody><tr>
              <td colspan="2" class="form-payment-methods form-multiple-column"><span class="form-radio-item"><input class="paymentMethod form-radio validate[required, paymentMethod] form-radio" type="radio" id="input_33_creditCard" name="q33_payment[payment_method]" value="creditCard" onclick="BuildSource.creditCard(this)" />
                  <label for="input_33_creditCard"> Credit Card </label>
                   </span><span class="form-radio-item"><input class="paymentMethod form-radio validate[required, paymentMethod] form-radio" type="radio" id="input_33_paypal" name="q33_payment[payment_method]" value="paypal" onclick="BuildSource.paypal(this)" />
                  <label for="input_33_paypal"> Paypal </label>
                   </span>
              </td>
            </tr>
            <tr class="credit_card hide">
              <th colspan="2">
                Credit Card
              </th>
            </tr>
            <tr class="credit_card hide">
              <td colspan="2" style="padding:0">
                <table cellpadding="0" cellspacing="0">
                  <tbody><tr>
                    <td colspan="2"><span class="form-sub-label-container"><select class="form-textbox validate[required, visible]" name="q33_payment[cc_type]" id="input_33_cc_type" autocomplete="cc-type">
                          <option value="Visa"> Visa </option>
                          <option value="Mastercard"> MasterCard </option>
                          <option value="Amex"> American Express </option>
                          <option value="Discover"> Discover </option>
                        </select>
                        <label class="form-sub-label" for="input_33_cc_type" id="sublabel_cc_type"> Credit Card Type </label></span>
                    </td>
                  </tr>
                  <tr>
                    <td><span class="form-sub-label-container"><input class="form-textbox form-creditcard js-cc-number validate[required, visible, creditcard]" type="text" name="q33_payment[cc_number]" id="input_33_cc_number" autocomplete="cc-number" size="20" />
                        <label class="form-sub-label" for="input_33_cc_number" id="sublabel_cc_number"> Credit Card Number </label></span>
                    </td>
                    <td class="cc_ccv "><span class="form-sub-label-container"><input class="form-textbox validate[required, visible]" type="text" name="q33_payment[cc_ccv]" id="input_33_cc_ccv" autocomplete="cc-csc" size="6" />
                        <label class="form-sub-label" for="input_33_cc_ccv" id="sublabel_cc_ccv"> Security Code </label></span>
                    </td>
                  </tr>
                  <tr>
                    <td colspan="2" class="cc_name_on_card "><span class="form-sub-label-container"><input class="form-textbox validate[required, visible]" type="text" name="q33_payment[cc_nameOnCard]" id="input_33_cc_nameOnCard" autocomplete="cc-name" size="33" />
                        <label class="form-sub-label" for="input_33_cc_nameOnCard" id="sublabel_cc_nameOnCard"> Name on Card </label></span>
                    </td>
                  </tr>
                  <tr class="credit_card hide">
                    <td colspan=""><span class="form-sub-label-container"><select class="form-textbox validate[required, visible]" name="q33_payment[cc_exp_month]" id="input_33_cc_exp_month" autocomplete="cc-exp-month">
                          <option>  </option>
                          <option value="1"> 1 - January </option>
                          <option value="2"> 2 - February </option>
                          <option value="3"> 3 - March </option>
                          <option value="4"> 4 - April </option>
                          <option value="5"> 5 - May </option>
                          <option value="6"> 6 - June </option>
                          <option value="7"> 7 - July </option>
                          <option value="8"> 8 - August </option>
                          <option value="9"> 9 - September </option>
                          <option value="10"> 10 - October </option>
                          <option value="11"> 11 - November </option>
                          <option value="12"> 12 - December </option>
                        </select>
                        <label class="form-sub-label" for="input_33_cc_exp_month" id="sublabel_cc_exp_month"> Expiration Month </label></span>
                    </td>
                    <td><span class="form-sub-label-container"><select class="form-textbox validate[required, visible]" name="q33_payment[cc_exp_year]" id="input_33_cc_exp_year" autocomplete="cc-exp-year">
                          <option>  </option>
                          <option value="2022"> 2022 </option>
                          <option value="2023"> 2023 </option>
                          <option value="2024"> 2024 </option>
                          <option value="2025"> 2025 </option>
                          <option value="2026"> 2026 </option>
                          <option value="2027"> 2027 </option>
                          <option value="2028"> 2028 </option>
                          <option value="2029"> 2029 </option>
                          <option value="2030"> 2030 </option>
                          <option value="2031"> 2031 </option>
                        </select>
                        <label class="form-sub-label" for="input_33_cc_exp_year" id="sublabel_cc_exp_year"> Expiration Year </label></span>
                    </td>
                  </tr>
                </tbody></table>
              </td>
            </tr>
            <tr class="paypal hide">
              <td colspan="2">
                Paypal has been selected. Payment will take place on the next page.
              </td>
            </tr>
            <tr class="billing_address hide">
              <th colspan="2">
                Billing Address
              </th>
            </tr>
            <tr class="billing_address hide">
              <td colspan="2"><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-line" type="text" name="q33_payment[addr_line1]" id="input_33_addr_line1" autocomplete="billing address-line1" />
                  <label class="form-sub-label" for="input_33_addr_line1" id="sublabel_33_addr_line1"> Street Address </label></span>
              </td>
            </tr>
            <tr class="billing_address hide">
              <td colspan="2"><span class="form-sub-label-container"><input class="form-textbox form-address-line no-validation" type="text" name="q33_payment[addr_line2]" id="input_33_addr_line2" size="46" autocomplete="billing address-line2" />
                  <label class="form-sub-label" for="input_33_addr_line2" id="sublabel_33_addr_line2"> Street Address Line 2 </label></span>
              </td>
            </tr>
            <tr class="billing_address hide">
              <td width="50%"><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-city" type="text" name="q33_payment[city]" id="input_33_city" autocomplete="billing address-level2" />
                  <label class="form-sub-label" for="input_33_city" id="sublabel_33_city"> City </label></span>
              </td>
              <td><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-state" type="text" name="q33_payment[state]" id="input_33_state" autocomplete="billing address-level1" />
                  <label class="form-sub-label" for="input_33_state" id="sublabel_33_state"> State / Province </label></span>
              </td>
            </tr>
            <tr class="billing_address hide">
              <td width="50%"><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-postal" type="text" name="q33_payment[postal]" id="input_33_postal" size="10" autocomplete="billing postal-code" />
                  <label class="form-sub-label" for="input_33_postal" id="sublabel_33_postal"> Postal / Zip Code </label></span>
              </td>
              <td><span class="form-sub-label-container"><select class="form-dropdown validate[required] form-address-country" name="q33_payment[country]" id="input_33_country" autocomplete="billing country-name">
                    <option value="" selected="selected"> Please Select </option>
                    <option value="United States"> United States </option>
                    <option value="Afghanistan"> Afghanistan </option>
                    <option value="Albania"> Albania </option>
                    <option value="Algeria"> Algeria </option>
                    <option value="American Samoa"> American Samoa </option>
                    <option value="Andorra"> Andorra </option>
                    <option value="Angola"> Angola </option>
                    <option value="Anguilla"> Anguilla </option>
                    <option value="Antigua and Barbuda"> Antigua and Barbuda </option>
                    <option value="Argentina"> Argentina </option>
                    <option value="Armenia"> Armenia </option>
                    <option value="Aruba"> Aruba </option>
                    <option value="Australia"> Australia </option>
                    <option value="Austria"> Austria </option>
                    <option value="Azerbaijan"> Azerbaijan </option>
                    <option value="The Bahamas"> The Bahamas </option>
                    <option value="Bahrain"> Bahrain </option>
                    <option value="Bangladesh"> Bangladesh </option>
                    <option value="Barbados"> Barbados </option>
                    <option value="Belarus"> Belarus </option>
                    <option value="Belgium"> Belgium </option>
                    <option value="Belize"> Belize </option>
                    <option value="Benin"> Benin </option>
                    <option value="Bermuda"> Bermuda </option>
                    <option value="Bhutan"> Bhutan </option>
                    <option value="Bolivia"> Bolivia </option>
                    <option value="Bosnia and Herzegovina"> Bosnia and Herzegovina </option>
                    <option value="Botswana"> Botswana </option>
                    <option value="Brazil"> Brazil </option>
                    <option value="Brunei"> Brunei </option>
                    <option value="Bulgaria"> Bulgaria </option>
                    <option value="Burkina Faso"> Burkina Faso </option>
                    <option value="Burundi"> Burundi </option>
                    <option value="Cambodia"> Cambodia </option>
                    <option value="Cameroon"> Cameroon </option>
                    <option value="Canada"> Canada </option>
                    <option value="Cape Verde"> Cape Verde </option>
                    <option value="Cayman Islands"> Cayman Islands </option>
                    <option value="Central African Republic"> Central African Republic </option>
                    <option value="Chad"> Chad </option>
                    <option value="Chile"> Chile </option>
                    <option value="People's Republic of China"> People's Republic of China </option>
                    <option value="Republic of China"> Republic of China </option>
                    <option value="Christmas Island"> Christmas Island </option>
                    <option value="Cocos (Keeling) Islands"> Cocos (Keeling) Islands </option>
                    <option value="Colombia"> Colombia </option>
                    <option value="Comoros"> Comoros </option>
                    <option value="Congo"> Congo </option>
                    <option value="Cook Islands"> Cook Islands </option>
                    <option value="Costa Rica"> Costa Rica </option>
                    <option value="Cote d'Ivoire"> Cote d'Ivoire </option>
                    <option value="Croatia"> Croatia </option>
                    <option value="Cuba"> Cuba </option>
                    <option value="Cyprus"> Cyprus </option>
                    <option value="Czech Republic"> Czech Republic </option>
                    <option value="Denmark"> Denmark </option>
                    <option value="Djibouti"> Djibouti </option>
                    <option value="Dominica"> Dominica </option>
                    <option value="Dominican Republic"> Dominican Republic </option>
                    <option value="Ecuador"> Ecuador </option>
                    <option value="Egypt"> Egypt </option>
                    <option value="El Salvador"> El Salvador </option>
                    <option value="Equatorial Guinea"> Equatorial Guinea </option>
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