{"id":209760,"date":"2023-11-11T17:31:49","date_gmt":"2023-11-11T17:31:49","guid":{"rendered":"https:\/\/www.fayac.com\/?page_id=209760"},"modified":"2024-03-27T01:30:17","modified_gmt":"2024-03-27T01:30:17","slug":"summercamp","status":"publish","type":"page","link":"https:\/\/www.fayac.com\/forms\/summercamp\/","title":{"rendered":"Summer Camp"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"209760\" class=\"elementor elementor-209760\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-3a59317 e-flex e-con-boxed e-con e-parent\" data-id=\"3a59317\" data-element_type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-b84179f elementor-arrows-position-inside elementor-widget elementor-widget-image-carousel\" data-id=\"b84179f\" data-element_type=\"widget\" data-settings=\"{&quot;slides_to_show&quot;:&quot;1&quot;,&quot;navigation&quot;:&quot;arrows&quot;,&quot;infinite&quot;:&quot;yes&quot;,&quot;effect&quot;:&quot;slide&quot;,&quot;speed&quot;:500}\" data-widget_type=\"image-carousel.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<style>\/*! elementor - v3.21.0 - 08-05-2024 *\/\n.elementor-widget-image-carousel .swiper,.elementor-widget-image-carousel .swiper-container{position:static}.elementor-widget-image-carousel .swiper-container .swiper-slide figure,.elementor-widget-image-carousel .swiper .swiper-slide figure{line-height:inherit}.elementor-widget-image-carousel .swiper-slide{text-align:center}.elementor-image-carousel-wrapper:not(.swiper-container-initialized):not(.swiper-initialized) .swiper-slide{max-width:calc(100% \/ var(--e-image-carousel-slides-to-show, 3))}<\/style>\t\t<div class=\"elementor-image-carousel-wrapper swiper\" dir=\"ltr\">\n\t\t\t<div class=\"elementor-image-carousel swiper-wrapper\" aria-live=\"polite\">\n\t\t\t\t\t\t\t\t<div class=\"swiper-slide\" role=\"group\" aria-roledescription=\"slide\" aria-label=\"1 of 8\"><figure class=\"swiper-slide-inner\"><img decoding=\"async\" class=\"swiper-slide-image\" src=\"https:\/\/www.fayac.com\/wp-content\/uploads\/2024\/03\/PAGE-1-FRONT-COVER.png\" alt=\"PAGE 1 FRONT COVER\" \/><\/figure><\/div><div class=\"swiper-slide\" role=\"group\" aria-roledescription=\"slide\" aria-label=\"2 of 8\"><figure class=\"swiper-slide-inner\"><img decoding=\"async\" class=\"swiper-slide-image\" src=\"https:\/\/www.fayac.com\/wp-content\/uploads\/2024\/03\/2024-Summer-Camp-Guide-page-2-of-8.png\" alt=\"2024 Summer Camp Guide page 2 of 8\" \/><\/figure><\/div><div class=\"swiper-slide\" role=\"group\" aria-roledescription=\"slide\" aria-label=\"3 of 8\"><figure class=\"swiper-slide-inner\"><img decoding=\"async\" class=\"swiper-slide-image\" src=\"https:\/\/www.fayac.com\/wp-content\/uploads\/2024\/03\/2024-Summer-Camp-Guide-page-3-of-8.png\" alt=\"2024 Summer Camp Guide page 3 of 8\" \/><\/figure><\/div><div class=\"swiper-slide\" role=\"group\" aria-roledescription=\"slide\" aria-label=\"4 of 8\"><figure class=\"swiper-slide-inner\"><img decoding=\"async\" class=\"swiper-slide-image\" src=\"https:\/\/www.fayac.com\/wp-content\/uploads\/2024\/03\/2024-Summer-Camp-Guide-page-4-of-8.png\" alt=\"2024 Summer Camp Guide page 4 of 8\" \/><\/figure><\/div><div class=\"swiper-slide\" role=\"group\" aria-roledescription=\"slide\" aria-label=\"5 of 8\"><figure class=\"swiper-slide-inner\"><img decoding=\"async\" class=\"swiper-slide-image\" src=\"https:\/\/www.fayac.com\/wp-content\/uploads\/2024\/03\/AGE-4-AND-5-FIELD-TRIP-PAGE.png\" alt=\"AGE 4 AND 5 FIELD TRIP PAGE\" \/><\/figure><\/div><div class=\"swiper-slide\" role=\"group\" aria-roledescription=\"slide\" aria-label=\"6 of 8\"><figure class=\"swiper-slide-inner\"><img decoding=\"async\" class=\"swiper-slide-image\" src=\"https:\/\/www.fayac.com\/wp-content\/uploads\/2024\/03\/SWIM-LESSON-PAGE.png\" alt=\"SWIM LESSON PAGE\" \/><\/figure><\/div><div class=\"swiper-slide\" role=\"group\" aria-roledescription=\"slide\" aria-label=\"7 of 8\"><figure class=\"swiper-slide-inner\"><img decoding=\"async\" class=\"swiper-slide-image\" src=\"https:\/\/www.fayac.com\/wp-content\/uploads\/2024\/03\/2024-Summer-Camp-Guide-page-7-of-8.png\" alt=\"2024 Summer Camp Guide page 7 of 8\" \/><\/figure><\/div><div class=\"swiper-slide\" role=\"group\" aria-roledescription=\"slide\" aria-label=\"8 of 8\"><figure class=\"swiper-slide-inner\"><img decoding=\"async\" class=\"swiper-slide-image\" src=\"https:\/\/www.fayac.com\/wp-content\/uploads\/2024\/03\/BACK-COVER-RIGHT.png\" alt=\"BACK COVER RIGHT\" \/><\/figure><\/div>\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t\t\t\t<div class=\"elementor-swiper-button elementor-swiper-button-prev\" role=\"button\" tabindex=\"0\">\n\t\t\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-chevron-left\"><\/i>\t\t\t\t\t<\/div>\n\t\t\t\t\t<div class=\"elementor-swiper-button elementor-swiper-button-next\" role=\"button\" tabindex=\"0\">\n\t\t\t\t\t\t<i aria-hidden=\"true\" class=\"eicon-chevron-right\"><\/i>\t\t\t\t\t<\/div>\n\t\t\t\t\n\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-7b80ee2 form e-flex e-con-boxed e-con e-parent\" data-id=\"7b80ee2\" data-element_type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-62ed9b2 elementor-widget elementor-widget-shortcode\" data-id=\"62ed9b2\" data-element_type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"elementor-shortcode\"><script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_unknown gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_58' >\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Summer Camp 2024 Registration<\/h2>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_58'  action='\/wp-json\/wp\/v2\/pages\/209760' data-formid='58' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_58' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_58_73\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_73\" ><h3 class=\"gsection_title\">2024 Hog Star Summer Camp - Camper Information (ages 5-12 years)<\/h3><\/div><fieldset id=\"field_58_1\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_1\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Child&#039;s Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_58_1'>\n                            \n                            <span id='input_58_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_58_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_58_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_58_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_58_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_58_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_58_7\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datefield gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_7\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Birth Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div id='input_58_7' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_58_7_1_container'>\n                                            <input type='number' maxlength='2' name='input_7[]' id='input_58_7_1' value=''   aria-required='true'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_58_7_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_58_7_2_container'>\n                                            <input type='number' maxlength='2' name='input_7[]' id='input_58_7_2' value=''   aria-required='true'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_58_7_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_58_7_3_container'>\n                                            <input type='number' maxlength='4' name='input_7[]' id='input_58_7_3' value=''   aria-required='true'   placeholder='YYYY' min='1920' max='2025' step='1'\/>\n                                            <label for='input_58_7_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><fieldset id=\"field_58_115\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_115\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Age as of June 1, 2024<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_58_115'><div class='gchoice gchoice_58_115_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.1' type='checkbox'  value='5 years old'  id='choice_58_115_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_58_115_1' id='label_58_115_1' class='gform-field-label gform-field-label--type-inline'>5 years old<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_58_115_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.2' type='checkbox'  value='6 years old'  id='choice_58_115_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_58_115_2' id='label_58_115_2' class='gform-field-label gform-field-label--type-inline'>6 years old<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_58_115_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.3' type='checkbox'  value='7 years old'  id='choice_58_115_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_58_115_3' id='label_58_115_3' class='gform-field-label gform-field-label--type-inline'>7 years old<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_58_115_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.4' type='checkbox'  value='8 years old'  id='choice_58_115_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_58_115_4' id='label_58_115_4' class='gform-field-label gform-field-label--type-inline'>8 years old<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_58_115_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.5' type='checkbox'  value='9 years old'  id='choice_58_115_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_58_115_5' id='label_58_115_5' class='gform-field-label gform-field-label--type-inline'>9 years old<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_58_115_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.6' type='checkbox'  value='10 years old'  id='choice_58_115_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_58_115_6' id='label_58_115_6' class='gform-field-label gform-field-label--type-inline'>10 years old<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_58_115_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.7' type='checkbox'  value='11 years old'  id='choice_58_115_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_58_115_7' id='label_58_115_7' class='gform-field-label gform-field-label--type-inline'>11 years old<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_58_115_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_115.8' type='checkbox'  value='12 years old'  id='choice_58_115_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_58_115_8' id='label_58_115_8' class='gform-field-label gform-field-label--type-inline'>12 years old<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_58_203\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_203\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Grade entering Fall 2024<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_58_203'><div class='gchoice gchoice_58_203_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_203.1' type='checkbox'  value='Kindergarten'  id='choice_58_203_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_58_203_1' id='label_58_203_1' class='gform-field-label gform-field-label--type-inline'>Kindergarten<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_58_203_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_203.2' type='checkbox'  value='1st Grade'  id='choice_58_203_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_58_203_2' id='label_58_203_2' class='gform-field-label gform-field-label--type-inline'>1st Grade<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_58_203_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_203.3' type='checkbox'  value='2nd Grade'  id='choice_58_203_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_58_203_3' id='label_58_203_3' class='gform-field-label gform-field-label--type-inline'>2nd Grade<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_58_203_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_203.4' type='checkbox'  value='3rd Grade'  id='choice_58_203_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_58_203_4' id='label_58_203_4' class='gform-field-label gform-field-label--type-inline'>3rd Grade<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_58_203_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_203.5' type='checkbox'  value='4th Grade'  id='choice_58_203_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_58_203_5' id='label_58_203_5' class='gform-field-label gform-field-label--type-inline'>4th Grade<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_58_203_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_203.6' type='checkbox'  value='5th Grade'  id='choice_58_203_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_58_203_6' id='label_58_203_6' class='gform-field-label gform-field-label--type-inline'>5th Grade<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_58_203_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_203.7' type='checkbox'  value='6th Grade'  id='choice_58_203_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_58_203_7' id='label_58_203_7' class='gform-field-label gform-field-label--type-inline'>6th Grade<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_58_103\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_103\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Primary Parent\/ Caregiver Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_58_103'>\n                            \n                            <span id='input_58_103_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_103.3' id='input_58_103_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_58_103_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_58_103_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_103.6' id='input_58_103_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_58_103_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_58_118\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_118\" ><label class='gfield_label gform-field-label' for='input_58_118'>Relationship to child:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_118' id='input_58_118' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_58_105\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_105\" ><label class='gfield_label gform-field-label' for='input_58_105'>1st Parent\/ Guardian Cell Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_105' id='input_58_105' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_58_120\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_120\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Home Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_58_120' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_58_120_1_container' >\n                                        <input type='text' name='input_120.1' id='input_58_120_1' value=''    aria-required='true'    \/>\n                                        <label for='input_58_120_1' id='input_58_120_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_58_120_2_container' >\n                                        <input type='text' name='input_120.2' id='input_58_120_2' value=''     aria-required='false'   \/>\n                                        <label for='input_58_120_2' id='input_58_120_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_58_120_3_container' >\n                                    <input type='text' name='input_120.3' id='input_58_120_3' value=''    aria-required='true'    \/>\n                                    <label for='input_58_120_3' id='input_58_120_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_58_120_4_container' >\n                                        <select name='input_120.4' id='input_58_120_4'     aria-required='true'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_58_120_4' id='input_58_120_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_58_120_5_container' >\n                                    <input type='text' name='input_120.5' id='input_58_120_5' value=''    aria-required='true'    \/>\n                                    <label for='input_58_120_5' id='input_58_120_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_120.6' id='input_58_120_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_58_124\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_124\" ><label class='gfield_label gform-field-label' for='input_58_124'>Primary Parent\/ Caregiver&#039;s Place of Employment<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_124' id='input_58_124' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_58_119\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_119\" ><label class='gfield_label gform-field-label' for='input_58_119'>Work Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_119' id='input_58_119' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_58_106\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_106\" ><label class='gfield_label gform-field-label' for='input_58_106'>1st Parent\/ Caregiver Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_106' id='input_58_106' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_58_108\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_108\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Secondary Caregiver Name<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_58_108'>\n                            \n                            <span id='input_58_108_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_108.3' id='input_58_108_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_58_108_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_58_108_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_108.6' id='input_58_108_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_58_108_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_58_121\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_121\" ><label class='gfield_label gform-field-label' for='input_58_121'>Secondary Caregiver Cell Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_121' id='input_58_121' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_58_123\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_123\" ><label class='gfield_label gform-field-label' for='input_58_123'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_123' id='input_58_123' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_58_109\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_109\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Secondary Caregiver Address<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_58_109' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_58_109_1_container' >\n                                        <input type='text' name='input_109.1' id='input_58_109_1' value=''    aria-required='false'    \/>\n                                        <label for='input_58_109_1' id='input_58_109_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_58_109_2_container' >\n                                        <input type='text' name='input_109.2' id='input_58_109_2' value=''     aria-required='false'   \/>\n                                        <label for='input_58_109_2' id='input_58_109_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_58_109_3_container' >\n                                    <input type='text' name='input_109.3' id='input_58_109_3' value=''    aria-required='false'    \/>\n                                    <label for='input_58_109_3' id='input_58_109_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_58_109_4_container' >\n                                        <select name='input_109.4' id='input_58_109_4'     aria-required='false'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_58_109_4' id='input_58_109_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_58_109_5_container' >\n                                    <input type='text' name='input_109.5' id='input_58_109_5' value=''    aria-required='false'    \/>\n                                    <label for='input_58_109_5' id='input_58_109_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_109.6' id='input_58_109_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_58_125\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_125\" ><label class='gfield_label gform-field-label' for='input_58_125'>Secondary Parent\/ Cargiver&#039;s Employer<\/label><div class='ginput_container ginput_container_text'><input name='input_125' id='input_58_125' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_58_126\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_126\" ><label class='gfield_label gform-field-label' for='input_58_126'>Secondary Parent\/ Caregiver Work Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_126' id='input_58_126' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_58_127\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_127\" ><label class='gfield_label gform-field-label' for='input_58_127'>EMERGENCY CONTACT \/NAME OF PERSON TO CALL IF PARENTS CAN NOT BE REACHED<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_127' id='input_58_127' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_58_129\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_129\" ><label class='gfield_label gform-field-label' for='input_58_129'>Emergency Contact Cell Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_129' id='input_58_129' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_58_130\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_130\" ><label class='gfield_label gform-field-label' for='input_58_130'>Emergency Contact Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_130' id='input_58_130' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_58_128\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_128\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Emergency Contact Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_58_128' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_58_128_1_container' >\n                                        <input type='text' name='input_128.1' id='input_58_128_1' value=''    aria-required='true'    \/>\n                                        <label for='input_58_128_1' id='input_58_128_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_58_128_2_container' >\n                                        <input type='text' name='input_128.2' id='input_58_128_2' value=''     aria-required='false'   \/>\n                                        <label for='input_58_128_2' id='input_58_128_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_58_128_3_container' >\n                                    <input type='text' name='input_128.3' id='input_58_128_3' value=''    aria-required='true'    \/>\n                                    <label for='input_58_128_3' id='input_58_128_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_58_128_4_container' >\n                                        <select name='input_128.4' id='input_58_128_4'     aria-required='true'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_58_128_4' id='input_58_128_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_58_128_5_container' >\n                                    <input type='text' name='input_128.5' id='input_58_128_5' value=''    aria-required='true'    \/>\n                                    <label for='input_58_128_5' id='input_58_128_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_128.6' id='input_58_128_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_58_132\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_132\" ><label class='gfield_label gform-field-label' for='input_58_132'>Is the emergency contact authorized to take the child from FAC?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_132' id='input_58_132' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='YES' >YES<\/option><option value='NO' >NO<\/option><\/select><\/div><\/div><div id=\"field_58_161\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_161\" ><h3 class=\"gsection_title\">List all other adults who are authorized to take the child from the center:<\/h3><\/div><fieldset id=\"field_58_139\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_139\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_58_139'>\n                            \n                            <span id='input_58_139_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_139.3' id='input_58_139_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_58_139_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_58_139_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_139.6' id='input_58_139_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_58_139_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_58_141\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_141\" ><label class='gfield_label gform-field-label' for='input_58_141'>Relationship<\/label><div class='ginput_container ginput_container_text'><input name='input_141' id='input_58_141' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_58_140\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_140\" ><label class='gfield_label gform-field-label' for='input_58_140'>Cell Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_140' id='input_58_140' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_58_142\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_142\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_58_142'>\n                            \n                            <span id='input_58_142_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_142.3' id='input_58_142_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_58_142_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_58_142_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_142.6' id='input_58_142_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_58_142_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_58_150\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_150\" ><label class='gfield_label gform-field-label' for='input_58_150'>Relationship<\/label><div class='ginput_container ginput_container_text'><input name='input_150' id='input_58_150' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_58_149\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_149\" ><label class='gfield_label gform-field-label' for='input_58_149'>Cell Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_149' id='input_58_149' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_58_151\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_151\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_58_151'>\n                            \n                            <span id='input_58_151_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_151.3' id='input_58_151_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_58_151_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_58_151_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_151.6' id='input_58_151_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_58_151_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_58_155\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_155\" ><label class='gfield_label gform-field-label' for='input_58_155'>Relationship<\/label><div class='ginput_container ginput_container_text'><input name='input_155' id='input_58_155' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_58_154\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_154\" ><label class='gfield_label gform-field-label' for='input_58_154'>Cell Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_154' id='input_58_154' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_58_99\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_99\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Select weeks camper will be attending<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_58_99'>Please visit our Summer Camp 2024 Guide (linked above) to review our 2024 Summer Camp Field Trips!<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_58_99'><div class='gchoice gchoice_58_99_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_99.1' type='checkbox'  value='Week 0 - May 28-31, 2024 (closed Monday\/Memorial Day)'  id='choice_58_99_1'   aria-describedby=\"gfield_description_58_99\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_58_99_1' id='label_58_99_1' class='gform-field-label gform-field-label--type-inline'>Week 0 - May 28-31, 2024 (closed Monday\/Memorial Day)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_58_99_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_99.2' type='checkbox'  value='Week 1 - June 3-7 - (Field Trips including Altitude, Siloam Springs Aquatic Center, Gulley Park, &amp; Veterans Park)'  id='choice_58_99_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_58_99_2' id='label_58_99_2' class='gform-field-label gform-field-label--type-inline'>Week 1 - June 3-7 - (Field Trips including Altitude, Siloam Springs Aquatic Center, Gulley Park, &amp; Veterans Park)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_58_99_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_99.3' type='checkbox'  value='Week 2 - June 10-14 - (Field Trips including Lake Fort Smith &amp; Springdale Aquatic Center)'  id='choice_58_99_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_58_99_3' id='label_58_99_3' class='gform-field-label gform-field-label--type-inline'>Week 2 - June 10-14 - (Field Trips including Lake Fort Smith &amp; Springdale Aquatic Center)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_58_99_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_99.4' type='checkbox'  value='Week 3 - June 17-21 - (Field Trips including Lokomotion, Tyson Park, Wilson Park &amp; Wilson Pool)'  id='choice_58_99_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_58_99_4' id='label_58_99_4' class='gform-field-label gform-field-label--type-inline'>Week 3 - June 17-21 - (Field Trips including Lokomotion, Tyson Park, Wilson Park &amp; Wilson Pool)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_58_99_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_99.5' type='checkbox'  value='Week 4 - June 24-28 - (Field Trips including Ozark Lanes, Willie George Park, Melvin Ford Pool, &amp; Orchards Park)'  id='choice_58_99_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_58_99_5' id='label_58_99_5' class='gform-field-label gform-field-label--type-inline'>Week 4 - June 24-28 - (Field Trips including Ozark Lanes, Willie George Park, Melvin Ford Pool, &amp; Orchards Park)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_58_99_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_99.6' type='checkbox'  value='Week 5 - July 1,2,3,5 - (Field Trips including Malco, Gator Golf, Bentonville Community Center, &amp; 28th St Park)'  id='choice_58_99_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_58_99_6' id='label_58_99_6' class='gform-field-label gform-field-label--type-inline'>Week 5 - July 1,2,3,5 - (Field Trips including Malco, Gator Golf, Bentonville Community Center, &amp; 28th St Park)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_58_99_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_99.7' type='checkbox'  value='Week 6 - July 8-12 - (Field Trips including Devils Den, Crystal Bridges, &amp; Osage Park)'  id='choice_58_99_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_58_99_7' id='label_58_99_7' class='gform-field-label gform-field-label--type-inline'>Week 6 - July 8-12 - (Field Trips including Devils Den, Crystal Bridges, &amp; Osage Park)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_58_99_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_99.8' type='checkbox'  value='Week 7 - July 15-19 - (Field Trips including Parrot Island, Carol Ann Cross Park, Prairie Grove Aquatics Center, &amp; Battlefield Park)'  id='choice_58_99_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_58_99_8' id='label_58_99_8' class='gform-field-label gform-field-label--type-inline'>Week 7 - July 15-19 - (Field Trips including Parrot Island, Carol Ann Cross Park, Prairie Grove Aquatics Center, &amp; Battlefield Park)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_58_99_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_99.9' type='checkbox'  value='Week 8 - July 22-26 - (Field Trips including Fast Lanes, Rogers Aquatic Center, &amp; Railyard Park)'  id='choice_58_99_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_58_99_9' id='label_58_99_9' class='gform-field-label gform-field-label--type-inline'>Week 8 - July 22-26 - (Field Trips including Fast Lanes, Rogers Aquatic Center, &amp; Railyard Park)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_58_99_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_99.11' type='checkbox'  value='Week 9 - July 29-Aug 2 - (Field Trips including Amazeum, Ozark Nature Center or Beaver Lake &amp; Roller City)'  id='choice_58_99_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_58_99_11' id='label_58_99_11' class='gform-field-label gform-field-label--type-inline'>Week 9 - July 29-Aug 2 - (Field Trips including Amazeum, Ozark Nature Center or Beaver Lake &amp; Roller City)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_58_99_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_99.12' type='checkbox'  value='Week 10 - Aug 5 - 9 - (Field Trips including SkyZone, Jones Center, &amp; Shogun)'  id='choice_58_99_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_58_99_12' id='label_58_99_12' class='gform-field-label gform-field-label--type-inline'>Week 10 - Aug 5 - 9 - (Field Trips including SkyZone, Jones Center, &amp; Shogun)<\/label>\n\t\t\t\t\t\t\t<\/div><button type=\"button\" id=\"button_99_select_all\" class=\"gfield_choice_all_toggle gform-theme-button--size-sm\" onclick=\"gformToggleCheckboxes( this )\" data-checked=\"0\" data-label-select=\"Select All\" data-label-deselect=\"Deselect All\">Select All<\/button><\/div><\/div><\/fieldset><fieldset id=\"field_58_205\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_205\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consent<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_205.1' id='input_58_205_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_58_205_1' >I understand that my child will be attending the field trips listed above and will be transported by the FAC buses and\/or vans. I grant the Fayetteville Athletic Club team permission to transport my child to\/from these locations. I also understand that I may NOT pick up my child from the field trip location(s).  Please sign below.<\/label><input type='hidden' name='input_205.2' value='I understand that my child will be attending the field trips listed above and will be transported by the FAC buses and\/or vans. I grant the Fayetteville Athletic Club team permission to transport my child to\/from these locations. I also understand that I may NOT pick up my child from the field trip location(s).  Please sign below.' class='gform_hidden' \/><input type='hidden' name='input_205.3' value='9' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_58_204\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_204\" ><label class='gfield_label gform-field-label' for='input_58_204'>Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_58_204_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_58_204_valid' id='input_58_204_valid' \/><canvas id='input_58_204' width='300' height='180'><\/canvas><div class='gfield_signature_reset_container'><svg id=\"input_58_204_resetIcon\" class=\"gfield_signature_reset_icon\" version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"26\" height=\"26\" viewBox=\"0 0 26 26\">\n\t\t\t\t\t<title>Reset signature<\/title>\n\t\t\t\t\t<path fill=\"#000000\" d=\"M13 6.906v1.939c0 0.487 0.585 0.726 0.921 0.379l3.022-3.023c0.217-0.217 0.217-0.553 0-0.769l-3.022-3.022c-0.336-0.336-0.921-0.098-0.921 0.39v1.939c-4.788 0-8.667 3.878-8.667 8.667 0 1.127 0.217 2.21 0.617 3.196 0.293 0.726 1.224 0.921 1.777 0.368 0.292-0.292 0.412-0.737 0.249-1.127-0.314-0.748-0.477-1.582-0.477-2.438 0-3.586 2.914-6.5 6.5-6.5zM19.273 9.842c-0.293 0.293-0.412 0.748-0.249 1.127 0.303 0.758 0.477 1.582 0.477 2.438 0 3.586-2.914 6.5-6.5 6.5v-1.939c0-0.488-0.585-0.726-0.921-0.379l-3.023 3.023c-0.217 0.217-0.217 0.552 0 0.769l3.023 3.023c0.336 0.336 0.921 0.098 0.921-0.379v-1.95c4.788 0 8.667-3.878 8.667-8.667 0-1.127-0.217-2.21-0.618-3.196-0.292-0.726-1.224-0.921-1.777-0.368z\"><\/path>\n\t\t\t\t<\/svg><svg id=\"input_58_204_lockedReset\" class=\"gform_signature_locked_reset\" version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"18\" height=\"18\" viewBox=\"0 0 26 26\">\n\t\t\t\t\t<title>Signature locked. Reset to sign again<\/title>\n\t\t\t\t\t<path fill=\"#000000\" d=\"M19.5 8.667h-1.083v-2.167c0-2.99-2.427-5.417-5.417-5.417s-5.417 2.427-5.417 5.417v2.167h-1.083c-1.192 0-2.167 0.975-2.167 2.167v10.833c0 1.192 0.975 2.167 2.167 2.167h13c1.192 0 2.167-0.975 2.167-2.167v-10.833c0-1.192-0.975-2.167-2.167-2.167zM13 18.417c-1.192 0-2.167-0.975-2.167-2.167s0.975-2.167 2.167-2.167c1.192 0 2.167 0.975 2.167 2.167s-0.975 2.167-2.167 2.167zM9.75 8.667v-2.167c0-1.798 1.452-3.25 3.25-3.25s3.25 1.452 3.25 3.25v2.167h-6.5z\"><\/path>\n\t\t\t\t\t<path fill=\"#000000\" d=\"M13 18.417c-1.192 0-2.167-0.975-2.167-2.167s0.975-2.167 2.167-2.167c1.192 0 2.167 0.975 2.167 2.167s-0.975 2.167-2.167 2.167z\"><\/path>\n\t\t\t\t<\/svg>\n\t\t\t\t\t\t<\/div><\/div><\/div><\/div><div id=\"field_58_49\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_49\" ><h3 class=\"gsection_title\">Camper Medical Information<\/h3><\/div><div id=\"field_58_48\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_48\" ><label class='gfield_label gform-field-label' for='input_58_48'>Allergies? (n\/a if none)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_48' id='input_58_48' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_58_50\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_50\" ><label class='gfield_label gform-field-label' for='input_58_50'>Physical or Emotional Concerns Your Child May Have:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_50' id='input_58_50' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_58_51\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_51\" ><label class='gfield_label gform-field-label' for='input_58_51'>Special Food Needs?<\/label><div class='ginput_container ginput_container_text'><input name='input_51' id='input_58_51' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_58_52\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_52\" ><label class='gfield_label gform-field-label' for='input_58_52'>Prescribed Diet:<\/label><div class='ginput_container ginput_container_text'><input name='input_52' id='input_58_52' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_58_53\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_53\" ><label class='gfield_label gform-field-label' for='input_58_53'>Other Conditions or Comments?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_53' id='input_58_53' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_58_60\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_60\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Please Select All of The Following Conditions\/Illnesses That Your Child Has Had:<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_58_60'><div class='gchoice gchoice_58_60_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.1' type='checkbox'  value='Measels'  id='choice_58_60_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_58_60_1' id='label_58_60_1' class='gform-field-label gform-field-label--type-inline'>Measels<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_58_60_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.2' type='checkbox'  value='Chicken Pox'  id='choice_58_60_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_58_60_2' id='label_58_60_2' class='gform-field-label gform-field-label--type-inline'>Chicken Pox<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_58_60_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.3' type='checkbox'  value='Defective Heart'  id='choice_58_60_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_58_60_3' id='label_58_60_3' class='gform-field-label gform-field-label--type-inline'>Defective Heart<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_58_60_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.4' type='checkbox'  value='Frequent Ear Infection'  id='choice_58_60_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_58_60_4' id='label_58_60_4' class='gform-field-label gform-field-label--type-inline'>Frequent Ear Infection<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_58_60_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.5' type='checkbox'  value='Diabetes'  id='choice_58_60_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_58_60_5' id='label_58_60_5' class='gform-field-label gform-field-label--type-inline'>Diabetes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_58_60_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.6' type='checkbox'  value='Mumps'  id='choice_58_60_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_58_60_6' id='label_58_60_6' class='gform-field-label gform-field-label--type-inline'>Mumps<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_58_60_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.7' type='checkbox'  value='Whooping Cough'  id='choice_58_60_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_58_60_7' id='label_58_60_7' class='gform-field-label gform-field-label--type-inline'>Whooping Cough<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_58_60_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.8' type='checkbox'  value='Sun Sensitivity'  id='choice_58_60_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_58_60_8' id='label_58_60_8' class='gform-field-label gform-field-label--type-inline'>Sun Sensitivity<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_58_60_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.9' type='checkbox'  value='Frequent Throat Infection'  id='choice_58_60_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_58_60_9' id='label_58_60_9' class='gform-field-label gform-field-label--type-inline'>Frequent Throat Infection<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_58_60_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.11' type='checkbox'  value='ADD\/ADHD'  id='choice_58_60_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_58_60_11' id='label_58_60_11' class='gform-field-label gform-field-label--type-inline'>ADD\/ADHD<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_58_60_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.12' type='checkbox'  value='German Measels'  id='choice_58_60_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_58_60_12' id='label_58_60_12' class='gform-field-label gform-field-label--type-inline'>German Measels<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_58_60_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.13' type='checkbox'  value='Positive TB Test'  id='choice_58_60_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_58_60_13' id='label_58_60_13' class='gform-field-label gform-field-label--type-inline'>Positive TB Test<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_58_60_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.14' type='checkbox'  value='Fainting Spells'  id='choice_58_60_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_58_60_14' id='label_58_60_14' class='gform-field-label gform-field-label--type-inline'>Fainting Spells<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_58_60_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.15' type='checkbox'  value='Frequent Colds'  id='choice_58_60_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_58_60_15' id='label_58_60_15' class='gform-field-label gform-field-label--type-inline'>Frequent Colds<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_58_60_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.16' type='checkbox'  value='Temper Tantrums'  id='choice_58_60_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_58_60_16' id='label_58_60_16' class='gform-field-label gform-field-label--type-inline'>Temper Tantrums<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_58_64\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_64\" ><label class='gfield_label gform-field-label' for='input_58_64'>Hospital Emergency Room of Choice:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_64' id='input_58_64' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_58_157\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_157\" ><label class='gfield_label gform-field-label' for='input_58_157'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_157' id='input_58_157' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_58_158\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_158\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_58_158' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_58_158_1_container' >\n                                        <input type='text' name='input_158.1' id='input_58_158_1' value=''    aria-required='true'    \/>\n                                        <label for='input_58_158_1' id='input_58_158_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_58_158_2_container' >\n                                        <input type='text' name='input_158.2' id='input_58_158_2' value=''     aria-required='false'   \/>\n                                        <label for='input_58_158_2' id='input_58_158_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_58_158_3_container' >\n                                    <input type='text' name='input_158.3' id='input_58_158_3' value=''    aria-required='true'    \/>\n                                    <label for='input_58_158_3' id='input_58_158_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_58_158_4_container' >\n                                        <select name='input_158.4' id='input_58_158_4'     aria-required='true'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_58_158_4' id='input_58_158_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_58_158_5_container' >\n                                    <input type='text' name='input_158.5' id='input_58_158_5' value=''    aria-required='true'    \/>\n                                    <label for='input_58_158_5' id='input_58_158_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_158.6' id='input_58_158_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_58_65\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_65\" ><label class='gfield_label gform-field-label' for='input_58_65'>I, (mother\/father\/guardian), do hereby give my consent to the Director of the Child Care facility, or his\/her representative, for said child to receive medical or surgical aid as may be deemed necessary and expedient by a duly licensed or recognized physician or surgeon in case of emergency when parent\/guardian can not be reached. Consent is also given for the Director or his\/her duly appointed representative to transport said child for emergency medical treatment, if the parents cannot be reached.  Please sign below.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_58_65_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_58_65_valid' id='input_58_65_valid' \/><canvas id='input_58_65' width='300' height='180'><\/canvas><div class='gfield_signature_reset_container'><svg id=\"input_58_65_resetIcon\" class=\"gfield_signature_reset_icon\" version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"26\" height=\"26\" viewBox=\"0 0 26 26\">\n\t\t\t\t\t<title>Reset signature<\/title>\n\t\t\t\t\t<path fill=\"#2f3192\" d=\"M13 6.906v1.939c0 0.487 0.585 0.726 0.921 0.379l3.022-3.023c0.217-0.217 0.217-0.553 0-0.769l-3.022-3.022c-0.336-0.336-0.921-0.098-0.921 0.39v1.939c-4.788 0-8.667 3.878-8.667 8.667 0 1.127 0.217 2.21 0.617 3.196 0.293 0.726 1.224 0.921 1.777 0.368 0.292-0.292 0.412-0.737 0.249-1.127-0.314-0.748-0.477-1.582-0.477-2.438 0-3.586 2.914-6.5 6.5-6.5zM19.273 9.842c-0.293 0.293-0.412 0.748-0.249 1.127 0.303 0.758 0.477 1.582 0.477 2.438 0 3.586-2.914 6.5-6.5 6.5v-1.939c0-0.488-0.585-0.726-0.921-0.379l-3.023 3.023c-0.217 0.217-0.217 0.552 0 0.769l3.023 3.023c0.336 0.336 0.921 0.098 0.921-0.379v-1.95c4.788 0 8.667-3.878 8.667-8.667 0-1.127-0.217-2.21-0.618-3.196-0.292-0.726-1.224-0.921-1.777-0.368z\"><\/path>\n\t\t\t\t<\/svg><svg id=\"input_58_65_lockedReset\" class=\"gform_signature_locked_reset\" version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"18\" height=\"18\" viewBox=\"0 0 26 26\">\n\t\t\t\t\t<title>Signature locked. Reset to sign again<\/title>\n\t\t\t\t\t<path fill=\"#2f3192\" d=\"M19.5 8.667h-1.083v-2.167c0-2.99-2.427-5.417-5.417-5.417s-5.417 2.427-5.417 5.417v2.167h-1.083c-1.192 0-2.167 0.975-2.167 2.167v10.833c0 1.192 0.975 2.167 2.167 2.167h13c1.192 0 2.167-0.975 2.167-2.167v-10.833c0-1.192-0.975-2.167-2.167-2.167zM13 18.417c-1.192 0-2.167-0.975-2.167-2.167s0.975-2.167 2.167-2.167c1.192 0 2.167 0.975 2.167 2.167s-0.975 2.167-2.167 2.167zM9.75 8.667v-2.167c0-1.798 1.452-3.25 3.25-3.25s3.25 1.452 3.25 3.25v2.167h-6.5z\"><\/path>\n\t\t\t\t\t<path fill=\"#2f3192\" d=\"M13 18.417c-1.192 0-2.167-0.975-2.167-2.167s0.975-2.167 2.167-2.167c1.192 0 2.167 0.975 2.167 2.167s-0.975 2.167-2.167 2.167z\"><\/path>\n\t\t\t\t<\/svg>\n\t\t\t\t\t\t<\/div><\/div><\/div><\/div><div id=\"field_58_160\" class=\"gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_160\" ><label class='gfield_label gform-field-label' for='input_58_160'>I give, or do not give the Director of the Kid&#039;s FACtory or his\/her appointed representative, permission to give my child Acetaminophen.  I understand that I will be notified if that medication has been administered<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_160' id='input_58_160' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='YES' >YES<\/option><option value='NO' >NO<\/option><\/select><\/div><\/div><div id=\"field_58_166\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_166\" ><label class='gfield_label gform-field-label' for='input_58_166'>Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_58_166_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_58_166_valid' id='input_58_166_valid' \/><canvas id='input_58_166' width='300' height='180'><\/canvas><div class='gfield_signature_reset_container'><svg id=\"input_58_166_resetIcon\" class=\"gfield_signature_reset_icon\" version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"26\" height=\"26\" viewBox=\"0 0 26 26\">\n\t\t\t\t\t<title>Reset signature<\/title>\n\t\t\t\t\t<path fill=\"#000000\" d=\"M13 6.906v1.939c0 0.487 0.585 0.726 0.921 0.379l3.022-3.023c0.217-0.217 0.217-0.553 0-0.769l-3.022-3.022c-0.336-0.336-0.921-0.098-0.921 0.39v1.939c-4.788 0-8.667 3.878-8.667 8.667 0 1.127 0.217 2.21 0.617 3.196 0.293 0.726 1.224 0.921 1.777 0.368 0.292-0.292 0.412-0.737 0.249-1.127-0.314-0.748-0.477-1.582-0.477-2.438 0-3.586 2.914-6.5 6.5-6.5zM19.273 9.842c-0.293 0.293-0.412 0.748-0.249 1.127 0.303 0.758 0.477 1.582 0.477 2.438 0 3.586-2.914 6.5-6.5 6.5v-1.939c0-0.488-0.585-0.726-0.921-0.379l-3.023 3.023c-0.217 0.217-0.217 0.552 0 0.769l3.023 3.023c0.336 0.336 0.921 0.098 0.921-0.379v-1.95c4.788 0 8.667-3.878 8.667-8.667 0-1.127-0.217-2.21-0.618-3.196-0.292-0.726-1.224-0.921-1.777-0.368z\"><\/path>\n\t\t\t\t<\/svg><svg id=\"input_58_166_lockedReset\" class=\"gform_signature_locked_reset\" version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"18\" height=\"18\" viewBox=\"0 0 26 26\">\n\t\t\t\t\t<title>Signature locked. Reset to sign again<\/title>\n\t\t\t\t\t<path fill=\"#000000\" d=\"M19.5 8.667h-1.083v-2.167c0-2.99-2.427-5.417-5.417-5.417s-5.417 2.427-5.417 5.417v2.167h-1.083c-1.192 0-2.167 0.975-2.167 2.167v10.833c0 1.192 0.975 2.167 2.167 2.167h13c1.192 0 2.167-0.975 2.167-2.167v-10.833c0-1.192-0.975-2.167-2.167-2.167zM13 18.417c-1.192 0-2.167-0.975-2.167-2.167s0.975-2.167 2.167-2.167c1.192 0 2.167 0.975 2.167 2.167s-0.975 2.167-2.167 2.167zM9.75 8.667v-2.167c0-1.798 1.452-3.25 3.25-3.25s3.25 1.452 3.25 3.25v2.167h-6.5z\"><\/path>\n\t\t\t\t\t<path fill=\"#000000\" d=\"M13 18.417c-1.192 0-2.167-0.975-2.167-2.167s0.975-2.167 2.167-2.167c1.192 0 2.167 0.975 2.167 2.167s-0.975 2.167-2.167 2.167z\"><\/path>\n\t\t\t\t<\/svg>\n\t\t\t\t\t\t<\/div><\/div><\/div><\/div><div id=\"field_58_164\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_164\" ><label class='gfield_label gform-field-label' for='input_58_164'>I give, or do not give the Director of the Kid&#039;s FACtory or his\/her appointed representative, permission to use sunscreen\/ suntan lotion on my child, when weather permits.  I understand that  school age children may apply sunscreen to themselves with supervision.This consent is in accordance with Minimum Licensing Requirements: DCCECE\/ Child Care Licensing Unit:  1100.1101.17<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_164' id='input_58_164' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='YES' >YES<\/option><option value='NO' >NO<\/option><\/select><\/div><\/div><div id=\"field_58_165\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_165\" ><label class='gfield_label gform-field-label' for='input_58_165'>Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_58_165_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_58_165_valid' id='input_58_165_valid' \/><canvas id='input_58_165' width='300' height='180'><\/canvas><div class='gfield_signature_reset_container'><svg id=\"input_58_165_resetIcon\" class=\"gfield_signature_reset_icon\" version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"26\" height=\"26\" viewBox=\"0 0 26 26\">\n\t\t\t\t\t<title>Reset signature<\/title>\n\t\t\t\t\t<path fill=\"#000000\" d=\"M13 6.906v1.939c0 0.487 0.585 0.726 0.921 0.379l3.022-3.023c0.217-0.217 0.217-0.553 0-0.769l-3.022-3.022c-0.336-0.336-0.921-0.098-0.921 0.39v1.939c-4.788 0-8.667 3.878-8.667 8.667 0 1.127 0.217 2.21 0.617 3.196 0.293 0.726 1.224 0.921 1.777 0.368 0.292-0.292 0.412-0.737 0.249-1.127-0.314-0.748-0.477-1.582-0.477-2.438 0-3.586 2.914-6.5 6.5-6.5zM19.273 9.842c-0.293 0.293-0.412 0.748-0.249 1.127 0.303 0.758 0.477 1.582 0.477 2.438 0 3.586-2.914 6.5-6.5 6.5v-1.939c0-0.488-0.585-0.726-0.921-0.379l-3.023 3.023c-0.217 0.217-0.217 0.552 0 0.769l3.023 3.023c0.336 0.336 0.921 0.098 0.921-0.379v-1.95c4.788 0 8.667-3.878 8.667-8.667 0-1.127-0.217-2.21-0.618-3.196-0.292-0.726-1.224-0.921-1.777-0.368z\"><\/path>\n\t\t\t\t<\/svg><svg id=\"input_58_165_lockedReset\" class=\"gform_signature_locked_reset\" version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"18\" height=\"18\" viewBox=\"0 0 26 26\">\n\t\t\t\t\t<title>Signature locked. Reset to sign again<\/title>\n\t\t\t\t\t<path fill=\"#000000\" d=\"M19.5 8.667h-1.083v-2.167c0-2.99-2.427-5.417-5.417-5.417s-5.417 2.427-5.417 5.417v2.167h-1.083c-1.192 0-2.167 0.975-2.167 2.167v10.833c0 1.192 0.975 2.167 2.167 2.167h13c1.192 0 2.167-0.975 2.167-2.167v-10.833c0-1.192-0.975-2.167-2.167-2.167zM13 18.417c-1.192 0-2.167-0.975-2.167-2.167s0.975-2.167 2.167-2.167c1.192 0 2.167 0.975 2.167 2.167s-0.975 2.167-2.167 2.167zM9.75 8.667v-2.167c0-1.798 1.452-3.25 3.25-3.25s3.25 1.452 3.25 3.25v2.167h-6.5z\"><\/path>\n\t\t\t\t\t<path fill=\"#000000\" d=\"M13 18.417c-1.192 0-2.167-0.975-2.167-2.167s0.975-2.167 2.167-2.167c1.192 0 2.167 0.975 2.167 2.167s-0.975 2.167-2.167 2.167z\"><\/path>\n\t\t\t\t<\/svg>\n\t\t\t\t\t\t<\/div><\/div><\/div><\/div><div id=\"field_58_168\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_168\" ><label class='gfield_label gform-field-label' for='input_58_168'>ACKNOWLEDGMENTS<\/label><div class='ginput_container ginput_container_text'><input name='input_168' id='input_58_168' type='text' value='' class='large'  aria-describedby=\"gfield_description_58_168\"    aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_58_168'>This is a statement of verification that I have been informed that child care licensing\/ child maltreatment investigators and\/or law enforcement may possibly interview my child for the purpose of determining licensing compliance or for investigative purposes.  This is accordance with Minimum Licensing Requirements: DCCEDE\/ Child Care Licensing Unit: 200.201.4<\/div><\/div><div id=\"field_58_169\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_169\" ><label class='gfield_label gform-field-label' for='input_58_169'>Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_58_169_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_58_169_valid' id='input_58_169_valid' \/><canvas id='input_58_169' width='300' height='180'><\/canvas><div class='gfield_signature_reset_container'><svg id=\"input_58_169_resetIcon\" class=\"gfield_signature_reset_icon\" version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"26\" height=\"26\" viewBox=\"0 0 26 26\">\n\t\t\t\t\t<title>Reset signature<\/title>\n\t\t\t\t\t<path fill=\"#000000\" d=\"M13 6.906v1.939c0 0.487 0.585 0.726 0.921 0.379l3.022-3.023c0.217-0.217 0.217-0.553 0-0.769l-3.022-3.022c-0.336-0.336-0.921-0.098-0.921 0.39v1.939c-4.788 0-8.667 3.878-8.667 8.667 0 1.127 0.217 2.21 0.617 3.196 0.293 0.726 1.224 0.921 1.777 0.368 0.292-0.292 0.412-0.737 0.249-1.127-0.314-0.748-0.477-1.582-0.477-2.438 0-3.586 2.914-6.5 6.5-6.5zM19.273 9.842c-0.293 0.293-0.412 0.748-0.249 1.127 0.303 0.758 0.477 1.582 0.477 2.438 0 3.586-2.914 6.5-6.5 6.5v-1.939c0-0.488-0.585-0.726-0.921-0.379l-3.023 3.023c-0.217 0.217-0.217 0.552 0 0.769l3.023 3.023c0.336 0.336 0.921 0.098 0.921-0.379v-1.95c4.788 0 8.667-3.878 8.667-8.667 0-1.127-0.217-2.21-0.618-3.196-0.292-0.726-1.224-0.921-1.777-0.368z\"><\/path>\n\t\t\t\t<\/svg><svg id=\"input_58_169_lockedReset\" class=\"gform_signature_locked_reset\" version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"18\" height=\"18\" viewBox=\"0 0 26 26\">\n\t\t\t\t\t<title>Signature locked. Reset to sign again<\/title>\n\t\t\t\t\t<path fill=\"#000000\" d=\"M19.5 8.667h-1.083v-2.167c0-2.99-2.427-5.417-5.417-5.417s-5.417 2.427-5.417 5.417v2.167h-1.083c-1.192 0-2.167 0.975-2.167 2.167v10.833c0 1.192 0.975 2.167 2.167 2.167h13c1.192 0 2.167-0.975 2.167-2.167v-10.833c0-1.192-0.975-2.167-2.167-2.167zM13 18.417c-1.192 0-2.167-0.975-2.167-2.167s0.975-2.167 2.167-2.167c1.192 0 2.167 0.975 2.167 2.167s-0.975 2.167-2.167 2.167zM9.75 8.667v-2.167c0-1.798 1.452-3.25 3.25-3.25s3.25 1.452 3.25 3.25v2.167h-6.5z\"><\/path>\n\t\t\t\t\t<path fill=\"#000000\" d=\"M13 18.417c-1.192 0-2.167-0.975-2.167-2.167s0.975-2.167 2.167-2.167c1.192 0 2.167 0.975 2.167 2.167s-0.975 2.167-2.167 2.167z\"><\/path>\n\t\t\t\t<\/svg>\n\t\t\t\t\t\t<\/div><\/div><\/div><\/div><fieldset id=\"field_58_172\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_172\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consent<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_172.1' id='input_58_172_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_58_172_1' >This is to acknowledge that I have received and will comply with the rules as stated in the Kids Fun FACtory Parent Handbook.<\/label><input type='hidden' name='input_172.2' value='This is to acknowledge that I have received and will comply with the rules as stated in the Kids Fun FACtory Parent Handbook.' class='gform_hidden' \/><input type='hidden' name='input_172.3' value='9' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_58_173\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_173\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consent<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_173.1' id='input_58_173_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_58_173_1' >I have been informed of the behavior guidance policy practiced.<\/label><input type='hidden' name='input_173.2' value='I have been informed of the behavior guidance policy practiced.' class='gform_hidden' \/><input type='hidden' name='input_173.3' value='9' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_58_174\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_174\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consent<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_174.1' id='input_58_174_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_58_174_1' >I understand that I may ask for a conference with the caregiver(s) as needed.<\/label><input type='hidden' name='input_174.2' value='I understand that I may ask for a conference with the caregiver(s) as needed.' class='gform_hidden' \/><input type='hidden' name='input_174.3' value='9' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_58_175\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_175\" ><label class='gfield_label gform-field-label' for='input_58_175'>Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_58_175_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_58_175_valid' id='input_58_175_valid' \/><canvas id='input_58_175' width='300' height='180'><\/canvas><div class='gfield_signature_reset_container'><svg id=\"input_58_175_resetIcon\" class=\"gfield_signature_reset_icon\" version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"26\" height=\"26\" viewBox=\"0 0 26 26\">\n\t\t\t\t\t<title>Reset signature<\/title>\n\t\t\t\t\t<path fill=\"#000000\" d=\"M13 6.906v1.939c0 0.487 0.585 0.726 0.921 0.379l3.022-3.023c0.217-0.217 0.217-0.553 0-0.769l-3.022-3.022c-0.336-0.336-0.921-0.098-0.921 0.39v1.939c-4.788 0-8.667 3.878-8.667 8.667 0 1.127 0.217 2.21 0.617 3.196 0.293 0.726 1.224 0.921 1.777 0.368 0.292-0.292 0.412-0.737 0.249-1.127-0.314-0.748-0.477-1.582-0.477-2.438 0-3.586 2.914-6.5 6.5-6.5zM19.273 9.842c-0.293 0.293-0.412 0.748-0.249 1.127 0.303 0.758 0.477 1.582 0.477 2.438 0 3.586-2.914 6.5-6.5 6.5v-1.939c0-0.488-0.585-0.726-0.921-0.379l-3.023 3.023c-0.217 0.217-0.217 0.552 0 0.769l3.023 3.023c0.336 0.336 0.921 0.098 0.921-0.379v-1.95c4.788 0 8.667-3.878 8.667-8.667 0-1.127-0.217-2.21-0.618-3.196-0.292-0.726-1.224-0.921-1.777-0.368z\"><\/path>\n\t\t\t\t<\/svg><svg id=\"input_58_175_lockedReset\" class=\"gform_signature_locked_reset\" version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"18\" height=\"18\" viewBox=\"0 0 26 26\">\n\t\t\t\t\t<title>Signature locked. Reset to sign again<\/title>\n\t\t\t\t\t<path fill=\"#000000\" d=\"M19.5 8.667h-1.083v-2.167c0-2.99-2.427-5.417-5.417-5.417s-5.417 2.427-5.417 5.417v2.167h-1.083c-1.192 0-2.167 0.975-2.167 2.167v10.833c0 1.192 0.975 2.167 2.167 2.167h13c1.192 0 2.167-0.975 2.167-2.167v-10.833c0-1.192-0.975-2.167-2.167-2.167zM13 18.417c-1.192 0-2.167-0.975-2.167-2.167s0.975-2.167 2.167-2.167c1.192 0 2.167 0.975 2.167 2.167s-0.975 2.167-2.167 2.167zM9.75 8.667v-2.167c0-1.798 1.452-3.25 3.25-3.25s3.25 1.452 3.25 3.25v2.167h-6.5z\"><\/path>\n\t\t\t\t\t<path fill=\"#000000\" d=\"M13 18.417c-1.192 0-2.167-0.975-2.167-2.167s0.975-2.167 2.167-2.167c1.192 0 2.167 0.975 2.167 2.167s-0.975 2.167-2.167 2.167z\"><\/path>\n\t\t\t\t<\/svg>\n\t\t\t\t\t\t<\/div><\/div><\/div><\/div><div id=\"field_58_177\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_177\" ><label class='gfield_label gform-field-label' for='input_58_177'>Discipline Policy<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_177' id='input_58_177' type='text' value='' class='large'  aria-describedby=\"gfield_description_58_177\"   aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_58_177'>The discipline policy of the Fayetteville Athletic Club, Kids Fit Fun FACtory will be that any time a child's behavior jeopardizes the safety of him\/herself, others or is acting in a disruptive manner, the child will be removed from the class or program.  The Kids FACtory uses \"timeout\" to encourage good behavior.  A child who has been given a \"timeout\" will be taken out of the group\/class participation and must sit alone quietly under staff supervision for 1 minute for each year of age.  After the 2nd offense, another timeout will be given.  Following a 3rd offense, the child will be sent home for the remainder of the day.  The parents and child will need to schedule a conference with the Director to discuss the issue.  Continuous or more serious behavior issues may result in suspension\/ pending termination from the Kid's Fit Fun FACtory program.  I understand and agree to comply with the Discipline Policy. <\/div><\/div><div id=\"field_58_201\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_201\" ><label class='gfield_label gform-field-label' for='input_58_201'>Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_58_201_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_58_201_valid' id='input_58_201_valid' \/><canvas id='input_58_201' width='300' height='180'><\/canvas><div class='gfield_signature_reset_container'><svg id=\"input_58_201_resetIcon\" class=\"gfield_signature_reset_icon\" version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"26\" height=\"26\" viewBox=\"0 0 26 26\">\n\t\t\t\t\t<title>Reset signature<\/title>\n\t\t\t\t\t<path fill=\"#000000\" d=\"M13 6.906v1.939c0 0.487 0.585 0.726 0.921 0.379l3.022-3.023c0.217-0.217 0.217-0.553 0-0.769l-3.022-3.022c-0.336-0.336-0.921-0.098-0.921 0.39v1.939c-4.788 0-8.667 3.878-8.667 8.667 0 1.127 0.217 2.21 0.617 3.196 0.293 0.726 1.224 0.921 1.777 0.368 0.292-0.292 0.412-0.737 0.249-1.127-0.314-0.748-0.477-1.582-0.477-2.438 0-3.586 2.914-6.5 6.5-6.5zM19.273 9.842c-0.293 0.293-0.412 0.748-0.249 1.127 0.303 0.758 0.477 1.582 0.477 2.438 0 3.586-2.914 6.5-6.5 6.5v-1.939c0-0.488-0.585-0.726-0.921-0.379l-3.023 3.023c-0.217 0.217-0.217 0.552 0 0.769l3.023 3.023c0.336 0.336 0.921 0.098 0.921-0.379v-1.95c4.788 0 8.667-3.878 8.667-8.667 0-1.127-0.217-2.21-0.618-3.196-0.292-0.726-1.224-0.921-1.777-0.368z\"><\/path>\n\t\t\t\t<\/svg><svg id=\"input_58_201_lockedReset\" class=\"gform_signature_locked_reset\" version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"18\" height=\"18\" viewBox=\"0 0 26 26\">\n\t\t\t\t\t<title>Signature locked. Reset to sign again<\/title>\n\t\t\t\t\t<path fill=\"#000000\" d=\"M19.5 8.667h-1.083v-2.167c0-2.99-2.427-5.417-5.417-5.417s-5.417 2.427-5.417 5.417v2.167h-1.083c-1.192 0-2.167 0.975-2.167 2.167v10.833c0 1.192 0.975 2.167 2.167 2.167h13c1.192 0 2.167-0.975 2.167-2.167v-10.833c0-1.192-0.975-2.167-2.167-2.167zM13 18.417c-1.192 0-2.167-0.975-2.167-2.167s0.975-2.167 2.167-2.167c1.192 0 2.167 0.975 2.167 2.167s-0.975 2.167-2.167 2.167zM9.75 8.667v-2.167c0-1.798 1.452-3.25 3.25-3.25s3.25 1.452 3.25 3.25v2.167h-6.5z\"><\/path>\n\t\t\t\t\t<path fill=\"#000000\" d=\"M13 18.417c-1.192 0-2.167-0.975-2.167-2.167s0.975-2.167 2.167-2.167c1.192 0 2.167 0.975 2.167 2.167s-0.975 2.167-2.167 2.167z\"><\/path>\n\t\t\t\t<\/svg>\n\t\t\t\t\t\t<\/div><\/div><\/div><\/div><div id=\"field_58_199\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_199\" ><label class='gfield_label gform-field-label' for='input_58_199'>CAMP PHOTOGRAPHY<\/label><div class='ginput_container ginput_container_text'><input name='input_199' id='input_58_199' type='text' value='' class='large'  aria-describedby=\"gfield_description_58_199\"    aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_58_199'>We will be taking pictures throughout the year to capture the action and adventure of our Kids FACtory programs. I hereby grant permission to Fayetteville Athletic Club to use photographs and\/or video of my child(ren) taken during FAC programs, in publications, news releases, online, \nand in other communications related to the Kid FACtory programs. <\/div><\/div><div id=\"field_58_202\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_202\" ><label class='gfield_label gform-field-label' for='input_58_202'>SELECT YES OR NO<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_202' id='input_58_202' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='YES' >YES<\/option><option value='NO' >NO<\/option><\/select><\/div><\/div><div id=\"field_58_178\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_178\" ><label class='gfield_label gform-field-label' for='input_58_178'>Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_58_178_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_58_178_valid' id='input_58_178_valid' \/><canvas id='input_58_178' width='300' height='180'><\/canvas><div class='gfield_signature_reset_container'><svg id=\"input_58_178_resetIcon\" class=\"gfield_signature_reset_icon\" version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"26\" height=\"26\" viewBox=\"0 0 26 26\">\n\t\t\t\t\t<title>Reset signature<\/title>\n\t\t\t\t\t<path fill=\"#000000\" d=\"M13 6.906v1.939c0 0.487 0.585 0.726 0.921 0.379l3.022-3.023c0.217-0.217 0.217-0.553 0-0.769l-3.022-3.022c-0.336-0.336-0.921-0.098-0.921 0.39v1.939c-4.788 0-8.667 3.878-8.667 8.667 0 1.127 0.217 2.21 0.617 3.196 0.293 0.726 1.224 0.921 1.777 0.368 0.292-0.292 0.412-0.737 0.249-1.127-0.314-0.748-0.477-1.582-0.477-2.438 0-3.586 2.914-6.5 6.5-6.5zM19.273 9.842c-0.293 0.293-0.412 0.748-0.249 1.127 0.303 0.758 0.477 1.582 0.477 2.438 0 3.586-2.914 6.5-6.5 6.5v-1.939c0-0.488-0.585-0.726-0.921-0.379l-3.023 3.023c-0.217 0.217-0.217 0.552 0 0.769l3.023 3.023c0.336 0.336 0.921 0.098 0.921-0.379v-1.95c4.788 0 8.667-3.878 8.667-8.667 0-1.127-0.217-2.21-0.618-3.196-0.292-0.726-1.224-0.921-1.777-0.368z\"><\/path>\n\t\t\t\t<\/svg><svg id=\"input_58_178_lockedReset\" class=\"gform_signature_locked_reset\" version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"18\" height=\"18\" viewBox=\"0 0 26 26\">\n\t\t\t\t\t<title>Signature locked. Reset to sign again<\/title>\n\t\t\t\t\t<path fill=\"#000000\" d=\"M19.5 8.667h-1.083v-2.167c0-2.99-2.427-5.417-5.417-5.417s-5.417 2.427-5.417 5.417v2.167h-1.083c-1.192 0-2.167 0.975-2.167 2.167v10.833c0 1.192 0.975 2.167 2.167 2.167h13c1.192 0 2.167-0.975 2.167-2.167v-10.833c0-1.192-0.975-2.167-2.167-2.167zM13 18.417c-1.192 0-2.167-0.975-2.167-2.167s0.975-2.167 2.167-2.167c1.192 0 2.167 0.975 2.167 2.167s-0.975 2.167-2.167 2.167zM9.75 8.667v-2.167c0-1.798 1.452-3.25 3.25-3.25s3.25 1.452 3.25 3.25v2.167h-6.5z\"><\/path>\n\t\t\t\t\t<path fill=\"#000000\" d=\"M13 18.417c-1.192 0-2.167-0.975-2.167-2.167s0.975-2.167 2.167-2.167c1.192 0 2.167 0.975 2.167 2.167s-0.975 2.167-2.167 2.167z\"><\/path>\n\t\t\t\t<\/svg>\n\t\t\t\t\t\t<\/div><\/div><\/div><\/div><fieldset id=\"field_58_179\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_179\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >FAC WAIVER RELEASE STATEMENT<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_179.1' id='input_58_179_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_58_179_1' >I agree to the Fayetteville Athletic Club's Waiver release statement.  By signing this form, I understand that I am releasing all claims for injury, I or my child may sustain through any of our programs.  I agree to assume full risk and to waive, relinquish, and release all claims I and\/or the participant may have against, indemnify, hold harmless and defend the Fayetteville Athletic Club.  This release includes FAC officers, agents, servants, and employees from such claims resulting from injury, damages, or loss sustained while participating in the FAC program or event.  I understand that I am responsible for all personal insurance and understand that I must cover any medical costs incurred for my family participating in this FAC program.  I also understand that every precaution is taken to protect the safety of each participant.<\/label><input type='hidden' name='input_179.2' value='I agree to the Fayetteville Athletic Club&#039;s Waiver release statement.  By signing this form, I understand that I am releasing all claims for injury, I or my child may sustain through any of our programs.  I agree to assume full risk and to waive, relinquish, and release all claims I and\/or the participant may have against, indemnify, hold harmless and defend the Fayetteville Athletic Club.  This release includes FAC officers, agents, servants, and employees from such claims resulting from injury, damages, or loss sustained while participating in the FAC program or event.  I understand that I am responsible for all personal insurance and understand that I must cover any medical costs incurred for my family participating in this FAC program.  I also understand that every precaution is taken to protect the safety of each participant.' class='gform_hidden' \/><input type='hidden' name='input_179.3' value='9' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_58_180\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_180\" ><label class='gfield_label gform-field-label' for='input_58_180'>Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_58_180_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_58_180_valid' id='input_58_180_valid' \/><canvas id='input_58_180' width='300' height='180'><\/canvas><div class='gfield_signature_reset_container'><svg id=\"input_58_180_resetIcon\" class=\"gfield_signature_reset_icon\" version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"26\" height=\"26\" viewBox=\"0 0 26 26\">\n\t\t\t\t\t<title>Reset signature<\/title>\n\t\t\t\t\t<path fill=\"#000000\" d=\"M13 6.906v1.939c0 0.487 0.585 0.726 0.921 0.379l3.022-3.023c0.217-0.217 0.217-0.553 0-0.769l-3.022-3.022c-0.336-0.336-0.921-0.098-0.921 0.39v1.939c-4.788 0-8.667 3.878-8.667 8.667 0 1.127 0.217 2.21 0.617 3.196 0.293 0.726 1.224 0.921 1.777 0.368 0.292-0.292 0.412-0.737 0.249-1.127-0.314-0.748-0.477-1.582-0.477-2.438 0-3.586 2.914-6.5 6.5-6.5zM19.273 9.842c-0.293 0.293-0.412 0.748-0.249 1.127 0.303 0.758 0.477 1.582 0.477 2.438 0 3.586-2.914 6.5-6.5 6.5v-1.939c0-0.488-0.585-0.726-0.921-0.379l-3.023 3.023c-0.217 0.217-0.217 0.552 0 0.769l3.023 3.023c0.336 0.336 0.921 0.098 0.921-0.379v-1.95c4.788 0 8.667-3.878 8.667-8.667 0-1.127-0.217-2.21-0.618-3.196-0.292-0.726-1.224-0.921-1.777-0.368z\"><\/path>\n\t\t\t\t<\/svg><svg id=\"input_58_180_lockedReset\" class=\"gform_signature_locked_reset\" version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"18\" height=\"18\" viewBox=\"0 0 26 26\">\n\t\t\t\t\t<title>Signature locked. Reset to sign again<\/title>\n\t\t\t\t\t<path fill=\"#000000\" d=\"M19.5 8.667h-1.083v-2.167c0-2.99-2.427-5.417-5.417-5.417s-5.417 2.427-5.417 5.417v2.167h-1.083c-1.192 0-2.167 0.975-2.167 2.167v10.833c0 1.192 0.975 2.167 2.167 2.167h13c1.192 0 2.167-0.975 2.167-2.167v-10.833c0-1.192-0.975-2.167-2.167-2.167zM13 18.417c-1.192 0-2.167-0.975-2.167-2.167s0.975-2.167 2.167-2.167c1.192 0 2.167 0.975 2.167 2.167s-0.975 2.167-2.167 2.167zM9.75 8.667v-2.167c0-1.798 1.452-3.25 3.25-3.25s3.25 1.452 3.25 3.25v2.167h-6.5z\"><\/path>\n\t\t\t\t\t<path fill=\"#000000\" d=\"M13 18.417c-1.192 0-2.167-0.975-2.167-2.167s0.975-2.167 2.167-2.167c1.192 0 2.167 0.975 2.167 2.167s-0.975 2.167-2.167 2.167z\"><\/path>\n\t\t\t\t<\/svg>\n\t\t\t\t\t\t<\/div><\/div><\/div><\/div><div id=\"field_58_183\" class=\"gfield gfield--type-post_title gfield--input-type-post_title gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_183\" ><label class='gfield_label gform-field-label' for='input_58_183'>SUMMER CAMP PAYMENT POLICY<\/label><div class='ginput_container ginput_container_post_title'>\n\t\t\t\t\t<input name='input_183' id='input_58_183' type='text' value='' class='large'    aria-invalid=\"false\" aria-describedby=\"gfield_description_58_183\" \/>\n\t\t\t\t<\/div><div class='gfield_description' id='gfield_description_58_183'>The Registration fee, first full week of camp fees must be paid to register for your child(ren)'s first week of summer camp.  Each subsequent week my be confirmed by placing a $25 non-refundable deposit on the week(s) that your camper will attend.  The balance for each week that has a deposit will be billed for the balance, the Wednesday prior to the week of camp.  This balance must be paid by a credit card or bank account on file with FAC.  Payments must be received for your camper to attend camp.  Non-payment by the required due dates will result in relinquishing the camper's space in the program.  FAC Junior Membership are required for each camper to receive the Member discount for our summer camp program.  Changes or cancellation requests must be received a minimum of 2 weeks prior to the start of camp and must be made in writing to the Director.  FAC member discounts will be voided and additional charges will occur if the FAC Junior membership is canceled at any time during the program duration.  A $25 returned payment fee will be applied to any returned payments.  Fayetteville Athletic Club accepts, Visa, Master Card, Discover, American Express, bank drafts and checks.  I agree to abide by the Billing policy that has been presented.  <\/div><\/div><div id=\"field_58_207\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_207\" ><label class='gfield_label gform-field-label' for='input_58_207'>Name as it appears on your credit card<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_207' id='input_58_207' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_58_209\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_209\" ><legend class='gfield_label gform-field-label' >Credit card type<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_58_209'>\n\t\t\t<div class='gchoice gchoice_58_209_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_209' type='radio' value='VISA'  id='choice_58_209_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_58_209_0' id='label_58_209_0' class='gform-field-label gform-field-label--type-inline'>VISA<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_58_209_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_209' type='radio' value='Mastercard'  id='choice_58_209_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_58_209_1' id='label_58_209_1' class='gform-field-label gform-field-label--type-inline'>Mastercard<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_58_209_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_209' type='radio' value='Discover'  id='choice_58_209_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_58_209_2' id='label_58_209_2' class='gform-field-label gform-field-label--type-inline'>Discover<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_58_209_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_209' type='radio' value='American Express'  id='choice_58_209_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_58_209_3' id='label_58_209_3' class='gform-field-label gform-field-label--type-inline'>American Express<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_58_213\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_213\" ><label class='gfield_label gform-field-label' for='input_58_213'>Credit card number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_213' id='input_58_213' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_58_214\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_214\" ><label class='gfield_label gform-field-label' for='input_58_214'>Expiration date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_214' id='input_58_214' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_58_212\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_212\" ><label class='gfield_label gform-field-label' for='input_58_212'>CVV<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_212' id='input_58_212' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_58_206\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_206\" ><label class='gfield_label gform-field-label' for='input_58_206'>Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_58_206_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_58_206_valid' id='input_58_206_valid' \/><canvas id='input_58_206' width='300' height='180'><\/canvas><div class='gfield_signature_reset_container'><svg id=\"input_58_206_resetIcon\" class=\"gfield_signature_reset_icon\" version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"26\" height=\"26\" viewBox=\"0 0 26 26\">\n\t\t\t\t\t<title>Reset signature<\/title>\n\t\t\t\t\t<path fill=\"#000000\" d=\"M13 6.906v1.939c0 0.487 0.585 0.726 0.921 0.379l3.022-3.023c0.217-0.217 0.217-0.553 0-0.769l-3.022-3.022c-0.336-0.336-0.921-0.098-0.921 0.39v1.939c-4.788 0-8.667 3.878-8.667 8.667 0 1.127 0.217 2.21 0.617 3.196 0.293 0.726 1.224 0.921 1.777 0.368 0.292-0.292 0.412-0.737 0.249-1.127-0.314-0.748-0.477-1.582-0.477-2.438 0-3.586 2.914-6.5 6.5-6.5zM19.273 9.842c-0.293 0.293-0.412 0.748-0.249 1.127 0.303 0.758 0.477 1.582 0.477 2.438 0 3.586-2.914 6.5-6.5 6.5v-1.939c0-0.488-0.585-0.726-0.921-0.379l-3.023 3.023c-0.217 0.217-0.217 0.552 0 0.769l3.023 3.023c0.336 0.336 0.921 0.098 0.921-0.379v-1.95c4.788 0 8.667-3.878 8.667-8.667 0-1.127-0.217-2.21-0.618-3.196-0.292-0.726-1.224-0.921-1.777-0.368z\"><\/path>\n\t\t\t\t<\/svg><svg id=\"input_58_206_lockedReset\" class=\"gform_signature_locked_reset\" version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"18\" height=\"18\" viewBox=\"0 0 26 26\">\n\t\t\t\t\t<title>Signature locked. Reset to sign again<\/title>\n\t\t\t\t\t<path fill=\"#000000\" d=\"M19.5 8.667h-1.083v-2.167c0-2.99-2.427-5.417-5.417-5.417s-5.417 2.427-5.417 5.417v2.167h-1.083c-1.192 0-2.167 0.975-2.167 2.167v10.833c0 1.192 0.975 2.167 2.167 2.167h13c1.192 0 2.167-0.975 2.167-2.167v-10.833c0-1.192-0.975-2.167-2.167-2.167zM13 18.417c-1.192 0-2.167-0.975-2.167-2.167s0.975-2.167 2.167-2.167c1.192 0 2.167 0.975 2.167 2.167s-0.975 2.167-2.167 2.167zM9.75 8.667v-2.167c0-1.798 1.452-3.25 3.25-3.25s3.25 1.452 3.25 3.25v2.167h-6.5z\"><\/path>\n\t\t\t\t\t<path fill=\"#000000\" d=\"M13 18.417c-1.192 0-2.167-0.975-2.167-2.167s0.975-2.167 2.167-2.167c1.192 0 2.167 0.975 2.167 2.167s-0.975 2.167-2.167 2.167z\"><\/path>\n\t\t\t\t<\/svg>\n\t\t\t\t\t\t<\/div><\/div><\/div><\/div><fieldset id=\"field_58_197\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_197\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >CHOOSE YOUR WEEKS - Please remember that your registration fee, your first full week of camp and all deposits for additional weeks must be paid at the time of enrollment to reserve your spots.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_58_197'><div class='gchoice gchoice_58_197_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_197.1' type='checkbox'  value='REGISTRATION FEE $30'  id='choice_58_197_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_58_197_1' id='label_58_197_1' class='gform-field-label gform-field-label--type-inline'>REGISTRATION FEE $30<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_58_197_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_197.2' type='checkbox'  value='WK 0-May 28-31 $159 Member\/ $191 Guest (holiday wk)'  id='choice_58_197_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_58_197_2' id='label_58_197_2' class='gform-field-label gform-field-label--type-inline'>WK 0-May 28-31 $159 Member\/ $191 Guest (holiday wk)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_58_197_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_197.3' type='checkbox'  value='WK 1-June 3-7   $199 Member\/ $239 Guest'  id='choice_58_197_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_58_197_3' id='label_58_197_3' class='gform-field-label gform-field-label--type-inline'>WK 1-June 3-7   $199 Member\/ $239 Guest<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_58_197_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_197.4' type='checkbox'  value='WK 2- June 10-14 $199 Member\/ $239 Guest\/ $25 deposit'  id='choice_58_197_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_58_197_4' id='label_58_197_4' class='gform-field-label gform-field-label--type-inline'>WK 2- June 10-14 $199 Member\/ $239 Guest\/ $25 deposit<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_58_197_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_197.5' type='checkbox'  value='WK 3- June 17-21 $199 Member\/ $239 Guest\/ $25 deposit'  id='choice_58_197_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_58_197_5' id='label_58_197_5' class='gform-field-label gform-field-label--type-inline'>WK 3- June 17-21 $199 Member\/ $239 Guest\/ $25 deposit<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_58_197_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_197.6' type='checkbox'  value='WK 4- June 24-28 $199 Member\/ $239 Guest\/ $25 deposit'  id='choice_58_197_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_58_197_6' id='label_58_197_6' class='gform-field-label gform-field-label--type-inline'>WK 4- June 24-28 $199 Member\/ $239 Guest\/ $25 deposit<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_58_197_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_197.7' type='checkbox'  value='WK 5- July 1,2,3&amp; 5 $159 Member\/ $191 Guest\/ $25 deposit'  id='choice_58_197_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_58_197_7' id='label_58_197_7' class='gform-field-label gform-field-label--type-inline'>WK 5- July 1,2,3&amp; 5 $159 Member\/ $191 Guest\/ $25 deposit<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_58_197_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_197.8' type='checkbox'  value='WK 6- July 8-12 $199 Member\/ $239 Guest\/ $25 deposit'  id='choice_58_197_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_58_197_8' id='label_58_197_8' class='gform-field-label gform-field-label--type-inline'>WK 6- July 8-12 $199 Member\/ $239 Guest\/ $25 deposit<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_58_197_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_197.9' type='checkbox'  value='WK 7- July 15-19  $199 Member\/ $239 Guest\/ $25 deposit'  id='choice_58_197_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_58_197_9' id='label_58_197_9' class='gform-field-label gform-field-label--type-inline'>WK 7- July 15-19  $199 Member\/ $239 Guest\/ $25 deposit<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_58_197_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_197.11' type='checkbox'  value='WK 8- July 22-26 $199 Member\/ $239 Guest\/ $25 deposit'  id='choice_58_197_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_58_197_11' id='label_58_197_11' class='gform-field-label gform-field-label--type-inline'>WK 8- July 22-26 $199 Member\/ $239 Guest\/ $25 deposit<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_58_197_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_197.12' type='checkbox'  value='WK 9- July 29-Aug 2  $199 Member\/ $239 Guest\/ $25 deposit'  id='choice_58_197_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_58_197_12' id='label_58_197_12' class='gform-field-label gform-field-label--type-inline'>WK 9- July 29-Aug 2  $199 Member\/ $239 Guest\/ $25 deposit<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_58_197_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_197.13' type='checkbox'  value='WK 10- Aug 5-8  $199 Member\/ $239 Guest\/ $25 deposit'  id='choice_58_197_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_58_197_13' id='label_58_197_13' class='gform-field-label gform-field-label--type-inline'>WK 10- Aug 5-8  $199 Member\/ $239 Guest\/ $25 deposit<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_58_215\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_58_215\" ><label class='gfield_label gform-field-label' for='input_58_215'>Signature<\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_58_215_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_58_215_valid' id='input_58_215_valid' \/><canvas id='input_58_215' width='300' height='180'><\/canvas><div class='gfield_signature_reset_container'><svg id=\"input_58_215_resetIcon\" class=\"gfield_signature_reset_icon\" version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"26\" height=\"26\" viewBox=\"0 0 26 26\">\n\t\t\t\t\t<title>Reset signature<\/title>\n\t\t\t\t\t<path fill=\"#000000\" d=\"M13 6.906v1.939c0 0.487 0.585 0.726 0.921 0.379l3.022-3.023c0.217-0.217 0.217-0.553 0-0.769l-3.022-3.022c-0.336-0.336-0.921-0.098-0.921 0.39v1.939c-4.788 0-8.667 3.878-8.667 8.667 0 1.127 0.217 2.21 0.617 3.196 0.293 0.726 1.224 0.921 1.777 0.368 0.292-0.292 0.412-0.737 0.249-1.127-0.314-0.748-0.477-1.582-0.477-2.438 0-3.586 2.914-6.5 6.5-6.5zM19.273 9.842c-0.293 0.293-0.412 0.748-0.249 1.127 0.303 0.758 0.477 1.582 0.477 2.438 0 3.586-2.914 6.5-6.5 6.5v-1.939c0-0.488-0.585-0.726-0.921-0.379l-3.023 3.023c-0.217 0.217-0.217 0.552 0 0.769l3.023 3.023c0.336 0.336 0.921 0.098 0.921-0.379v-1.95c4.788 0 8.667-3.878 8.667-8.667 0-1.127-0.217-2.21-0.618-3.196-0.292-0.726-1.224-0.921-1.777-0.368z\"><\/path>\n\t\t\t\t<\/svg><svg id=\"input_58_215_lockedReset\" class=\"gform_signature_locked_reset\" version=\"1.1\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"18\" height=\"18\" viewBox=\"0 0 26 26\">\n\t\t\t\t\t<title>Signature locked. 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