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	Scholarship Fund - Chabad Jewish Center of South Metro Denver 
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<form class="userform-form" action="" method="post" name="form_3766924" id="3766924" accept-charset="utf-8"><input type="hidden" name="formID" value="3766924" /><div class="form-all dir_ltr" dir="ltr"><ul class="form-section"><li id="cid_3" class="form-input-wide"> <div class="form-header-group"><h2 id="header_3" class="form-header">Summer Camp Scholarship Fund</h2></div> </li><li class="form-line" id="id_4"><div id="cid_4" class="form-input-wide"> <div id="text_4" class="form-html"><p>Our scholarship fund is running low, and the need continues to grow. We are counting on your kindness and generosity to help us say "YES" to every child who needs assistance. Your gift will enable a child to experience an unforgettable summer filled with friendship, fun, adventure, and a deep sense of Jewish pride and identity.</p>

<p>Please make your gift Today. </p>

<p>Donations are Tax Deductible and eligible for the<strong> Colorado contribution Child Care credit</strong></p>
</div> </div></li><li class="form-line" id="id_1"><div class="form-label-left" id="label_1"><label for="input_1"> Yes! I would like to sponsor a child for:<span class="form-required">*</span> </label><label class="label-message" for="input_1"> </label></div><div id="cid_1" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_1_0" name="q1_input1[]" value="1 session ($350)" /><label id="label_input_1_0" for="input_1_0"><span>1 session ($350)</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_1_1" name="q1_input1[]" value="2 sessions ($700)" /><label id="label_input_1_1" for="input_1_1"><span>2 sessions ($700)</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_1_2" name="q1_input1[]" value="3 sessions ($1,050)" /><label id="label_input_1_2" for="input_1_2"><span>3 sessions ($1,050)</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_1_3" name="q1_input1[]" value="4 sessions ($1,400)" /><label id="label_input_1_3" for="input_1_3"><span>4 sessions ($1,400)</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_1_4" name="q1_input1[]" value="5 sessions ($1,750)" /><label id="label_input_1_4" for="input_1_4"><span>5 sessions ($1,750)</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox validate[required]" id="input_1_5" name="q1_input1[]" value="6 sessions ($2,100)" /><label id="label_input_1_5" for="input_1_5"><span>6 sessions ($2,100)</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox-other form-checkbox validate[required, other]" name="q1_input1[other]" id="other_1" value="" /><span><input type="number" min="1" onkeypress="validateNumber(event)" class="form-checkbox-other-input form-textbox undefined" name="q1_input1[other][text]" data-otherhint="Other" size="15" id="input_1" disabled="disabled" /></span><br /></span></div> </div></li><li class="form-line" id="id_5"><div id="cid_5" class="form-input-wide"> <div id="text_5" class="form-html"><table dir="ltr" cellspacing="0" cellpadding="4" width="663" align="center" style="color: rgb(0, 0, 0); font-size: 14px; font-family: Arial; line-height: 1.2; border-collapse: collapse; background-color: rgb(255, 255, 255);"><tbody><tr><td bgcolor="339966" height="15" width="617" colspan="5" style="font-size: 10px;"><span style="font-size: 16px;"><font color="#ffffff" face="Tahoma"><span style="font-size: 14px; line-height: 17.4545px;"><strong>If you, or someone you know would like a scholarship please email info@DenverJewishCenter.com</strong></span></font></span></td></tr></tbody></table></div> </div></li><li id="cid_6" class="form-input-wide"> <div class="form-header-group"><h2 id="header_6" class="form-header">Personal Information</h2></div> </li><li class="form-line" id="id_7"><div class="form-label-left" id="label_7"><label for="input_7"> Full Name<span class="form-required">*</span> </label><label class="label-message" for="input_7"> </label></div><div id="cid_7" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q7_fullName[first]" id="first_7" autocomplete="given-name" />  <label class="form-sub-label" for="first_7" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q7_fullName[last]" id="last_7" autocomplete="family-name" />  <label class="form-sub-label" for="last_7" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_8"><div class="form-label-left" id="label_8"><label for="input_8"> E-mail<span class="form-required">*</span> </label><label class="label-message" for="input_8"> </label></div><div id="cid_8" class="form-input"> <input type="email" class=" form-textbox validate[required, Email]" id="input_8" name="q8_email" size="30" value="" autocomplete="email" /> </div></li><li class="form-line" id="id_10"><div class="form-label-left" id="label_10"><label for="input_10"> Phone Number<span class="form-required">*</span> </label><label class="label-message" for="input_10"> </label></div><div id="cid_10" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox validate[required, Numeric]" type="tel" name="q10_phoneNumber[area]" id="input_10_area" autocomplete="tel-area-code" maxlength="5" size="3" />  <label class="form-sub-label" for="input_10_area" id="sublabel_area">Area Code</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required, Numeric]" type="tel" name="q10_phoneNumber[phone]" id="input_10_phone" autocomplete="tel-local" size="8" />  <label class="form-sub-label" for="input_10_phone" id="sublabel_phone">Phone Number</label></span></div> </div></li><li class="form-line" id="id_9"><div class="form-label-left form-label-hidden" id="label_9"></div><div id="cid_9" class="form-input"> <div class="form-single-column form-checkbox-item"><input name="optin" value="true" type="checkbox" checked="checked" class="form-checkbox" id="input_9" /><label id="label_input_9" for="input_9">I would like to receive news and updates by email</label></div> </div></li><li id="cid_12" class="form-input-wide"> <div class="form-header-group"><h2 id="header_12" class="form-header">Payment Information</h2></div> </li><li class="form-line" id="id_13"><div class="form-label-left" id="label_13"><label for="input_13"> Total </label></div><div id="cid_13" class="form-input"> <div id="total_amount">$0.00 </div> </div></li><li class="form-line" id="id_11"><div class="form-label-left" id="label_11"><label for="input_11"> Payment<span class="form-required">*</span> </label><label class="label-message" for="input_11"> </label></div><div id="cid_11" class="form-input"> <table summary="" class="form-address-table" border="0" cellpadding="0" cellspacing="0"><tbody><tr><td colspan="2" class="form-payment-methods form-multiple-column"><span class="form-radio-item"><input class="paymentMethod form-radio validate[required, paymentMethod] form-radio" type="radio" id="input_11_creditCard" name="q11_payment[payment_method]" value="creditCard" onclick="BuildSource.creditCard(this)" /><label for="input_11_creditCard">Credit Card</label> </span><span class="form-radio-item"><input class="paymentMethod form-radio validate[required, paymentMethod] form-radio" type="radio" id="input_11_other" name="q11_payment[payment_method]" value="other" onclick="BuildSource.other(this)" /><label for="input_11_other">Check</label> </span></td></tr><tr class="credit_card hide"><th colspan="2">Credit Card</th></tr><tr class="credit_card hide"><td colspan="2" style="padding:0"><table cellpadding="0" cellspacing="0"><tbody><tr><td colspan="2"><span class="form-sub-label-container">  <label class="form-sub-label">We accept Visa, MasterCard, American Express</label></span><div class="cc-icons"><div class="cc-icon visa-icon"></div><div class="cc-icon mastercard-icon"></div><div class="cc-icon amex-icon"></div></div><input type="hidden" name="q11_payment[cc_type]" id="input_11_cc_type" value="" /></td></tr><tr><td><div class="cc-field-wrapper"><span class="form-sub-label-container"><input class="form-textbox form-creditcard js-cc-number validate[required, visible, creditcard]" type="text" name="q11_payment[cc_number]" id="input_11_cc_number" autocomplete="cc-number" size="20" />  <label class="form-sub-label" for="input_11_cc_number" id="sublabel_cc_number">Credit Card Number</label></span></div></td><td class="cc_ccv "><span class="form-sub-label-container"><input class="form-textbox validate[required, visible]" type="text" name="q11_payment[cc_ccv]" id="input_11_cc_ccv" autocomplete="cc-csc" size="6" />  <label class="form-sub-label" for="input_11_cc_ccv" id="sublabel_cc_ccv">Security Code</label></span></td></tr><tr><td colspan="2" class="cc_name_on_card "><span class="form-sub-label-container"><input class="form-textbox validate[required, visible]" type="text" name="q11_payment[cc_nameOnCard]" id="input_11_cc_nameOnCard" autocomplete="cc-name" size="33" />  <label class="form-sub-label" for="input_11_cc_nameOnCard" id="sublabel_cc_nameOnCard">Name on Card</label></span></td></tr><tr class="credit_card hide"><td colspan=""><span class="form-sub-label-container"><select class="form-textbox validate[required, visible]" name="q11_payment[cc_exp_month]" id="input_11_cc_exp_month" autocomplete="cc-exp-month"><option></option><option value="1">1 - January</option><option value="2">2 - February</option><option value="3">3 - March</option><option value="4">4 - April</option><option value="5">5 - May</option><option value="6">6 - June</option><option value="7">7 - July</option><option value="8">8 - August</option><option value="9">9 - September</option><option value="10">10 - October</option><option value="11">11 - November</option><option value="12">12 - December</option></select>  <label class="form-sub-label" for="input_11_cc_exp_month" id="sublabel_cc_exp_month">Expiration Month</label></span></td><td><span class="form-sub-label-container"><select class="form-textbox validate[required, visible]" name="q11_payment[cc_exp_year]" id="input_11_cc_exp_year" autocomplete="cc-exp-year"><option></option><option value="2026">2026</option><option value="2027">2027</option><option value="2028">2028</option><option value="2029">2029</option><option value="2030">2030</option><option value="2031">2031</option><option value="2032">2032</option><option value="2033">2033</option><option value="2034">2034</option><option value="2035">2035</option></select>  <label class="form-sub-label" for="input_11_cc_exp_year" id="sublabel_cc_exp_year">Expiration Year</label></span></td></tr></tbody></table></td></tr><tr class="other hide"><td colspan="2">Check Memo: Camp Gan Izzy Scholarship Fund</td></tr><tr class="billing_address hide"><th colspan="2">Billing Address</th></tr><tr class="billing_address hide"><td colspan="2"><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-line" type="text" name="q11_payment[addr_line1]" id="input_11_addr_line1" autocomplete="billing address-line1" />  <label class="form-sub-label" for="input_11_addr_line1" id="sublabel_11_addr_line1">Street Address</label></span></td></tr><tr class="billing_address hide"><td width="50%"><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-city" type="text" name="q11_payment[city]" id="input_11_city" autocomplete="billing address-level2" />  <label class="form-sub-label" for="input_11_city" id="sublabel_11_city">City</label></span></td><td><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-state" type="text" name="q11_payment[state]" id="input_11_state" autocomplete="billing address-level1" />  <label class="form-sub-label" for="input_11_state" id="sublabel_11_state">State / Province</label></span></td></tr><tr class="billing_address hide"><td width="50%"><span class="form-sub-label-container"><input class="form-textbox validate[required] form-address-postal" type="text" name="q11_payment[postal]" id="input_11_postal" size="10" autocomplete="billing postal-code" />  <label class="form-sub-label" for="input_11_postal" id="sublabel_11_postal">Postal / Zip Code</label></span></td><td><span class="form-sub-label-container"><select class="form-dropdown validate[required] form-address-country" name="q11_payment[country]" id="input_11_country" autocomplete="billing country-name"><option value="" selected="selected">Please Select</option><option value="United States">United States</option><option value="Afghanistan">Afghanistan</option><option value="Albania">Albania</option><option value="Algeria">Algeria</option><option value="American Samoa">American Samoa</option><option value="Andorra">Andorra</option><option value="Angola">Angola</option><option value="Anguilla">Anguilla</option><option value="Antigua and Barbuda">Antigua and Barbuda</option><option value="Argentina">Argentina</option><option value="Armenia">Armenia</option><option value="Aruba">Aruba</option><option value="Australia">Australia</option><option value="Austria">Austria</option><option value="Azerbaijan">Azerbaijan</option><option value="The Bahamas">The Bahamas</option><option value="Bahrain">Bahrain</option><option value="Bangladesh">Bangladesh</option><option value="Barbados">Barbados</option><option value="Belarus">Belarus</option><option value="Belgium">Belgium</option><option value="Belize">Belize</option><option value="Benin">Benin</option><option value="Bermuda">Bermuda</option><option value="Bhutan">Bhutan</option><option value="Bolivia">Bolivia</option><option value="Bosnia and Herzegovina">Bosnia and Herzegovina</option><option value="Botswana">Botswana</option><option value="Brazil">Brazil</option><option value="Brunei">Brunei</option><option value="Bulgaria">Bulgaria</option><option value="Burkina Faso">Burkina Faso</option><option value="Burundi">Burundi</option><option value="Cambodia">Cambodia</option><option value="Cameroon">Cameroon</option><option value="Canada">Canada</option><option value="Cape Verde">Cape Verde</option><option value="Cayman Islands">Cayman Islands</option><option value="Central African Republic">Central African Republic</option><option value="Chad">Chad</option><option value="Chile">Chile</option><option value="People's Republic of China">People's Republic of China</option><option value="Republic of China">Republic of China</option><option value="Christmas Island">Christmas Island</option><option value="Cocos (Keeling) Islands">Cocos (Keeling) Islands</option><option value="Colombia">Colombia</option><option value="Comoros">Comoros</option><option value="Congo">Congo</option><option value="Cook Islands">Cook Islands</option><option value="Costa Rica">Costa Rica</option><option value="Cote d'Ivoire">Cote d'Ivoire</option><option value="Croatia">Croatia</option><option value="Cuba">Cuba</option><option value="Cyprus">Cyprus</option><option value="Czech Republic">Czech Republic</option><option value="Denmark">Denmark</option><option value="Djibouti">Djibouti</option><option value="Dominica">Dominica</option><option value="Dominican Republic">Dominican Republic</option><option value="Ecuador">Ecuador</option><option value="Egypt">Egypt</option><option value="El Salvador">El Salvador</option><option value="Equatorial Guinea">Equatorial Guinea</option><option value="Eritrea">Eritrea</option><option value="Estonia">Estonia</option><option value="Eswatini">Eswatini</option><option value="Ethiopia">Ethiopia</option><option value="Falkland Islands">Falkland Islands</option><option value="Faroe Islands">Faroe Islands</option><option value="Fiji">Fiji</option><option value="Finland">Finland</option><option value="France">France</option><option value="French Polynesia">French Polynesia</option><option value="Gabon">Gabon</option><option value="The Gambia">The Gambia</option><option value="Georgia">Georgia</option><option value="Germany">Germany</option><option value="Ghana">Ghana</option><option value="Gibraltar">Gibraltar</option><option value="Greece">Greece</option><option value="Greenland">Greenland</option><option 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value="Nigeria">Nigeria</option><option value="Niue">Niue</option><option value="Norfolk Island">Norfolk Island</option><option value="Northern Mariana">Northern Mariana</option><option value="Norway">Norway</option><option value="Oman">Oman</option><option value="Pakistan">Pakistan</option><option value="Palau">Palau</option><option value="Panama">Panama</option><option value="Papua New Guinea">Papua New Guinea</option><option value="Paraguay">Paraguay</option><option value="Peru">Peru</option><option value="Philippines">Philippines</option><option value="Pitcairn Islands">Pitcairn Islands</option><option value="Poland">Poland</option><option value="Portugal">Portugal</option><option value="Puerto Rico">Puerto Rico</option><option value="Qatar">Qatar</option><option value="Romania">Romania</option><option value="Russia">Russia</option><option value="Rwanda">Rwanda</option><option value="Saint Barthelemy">Saint Barthelemy</option><option value="Saint Helena">Saint Helena</option><option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option><option value="Saint Lucia">Saint Lucia</option><option value="Saint Martin">Saint Martin</option><option value="Saint Pierre and Miquelon">Saint Pierre and Miquelon</option><option value="Saint Vincent and the Grenadines">Saint Vincent and the Grenadines</option><option value="Samoa">Samoa</option><option value="San Marino">San Marino</option><option value="Sao Tome and Principe">Sao Tome and Principe</option><option value="Saudi Arabia">Saudi Arabia</option><option value="Senegal">Senegal</option><option value="Serbia">Serbia</option><option value="Seychelles">Seychelles</option><option value="Sierra Leone">Sierra Leone</option><option value="Singapore">Singapore</option><option value="Slovakia">Slovakia</option><option value="Slovenia">Slovenia</option><option value="Solomon Islands">Solomon Islands</option><option value="Somalia">Somalia</option><option value="Somaliland">Somaliland</option><option 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