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	Children/Teens - Chabad Lubavitch of Western Monmouth County
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			<h1 class="article-header__title js-article-title js-page-title">Children/Teens</h1>
		
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<form class="userform-form" action="" method="post" name="form_3408132" id="3408132" accept-charset="utf-8"><input type="hidden" name="formID" value="3408132" /><div class="form-all dir_ltr" dir="ltr"><ul class="form-section"><li class="form-line" id="id_21"><div id="cid_21" class="form-input-wide"> <div style="text-align:center;"><img alt="" class="form-image" border="0" src="https://chabadwmc.com/media/images/1239/KoCX12394977.jpeg" height="493" width="371" /></div> </div></li><li class="form-line" id="id_1"><div id="cid_1" class="form-input-wide"> <div id="text_1" class="form-html"><div style="text-align: center;"><span style="font-size:16px;"><b>Children &amp; Teen Program (in addition to the Main Service)</b><br />
<br />
Children's Program at Project Rosh is <strong>in Memory of Michelle Begelfer OBM</strong><br />
<br />
Get ready for a fun and hands on program filled with learning, exploring, and praying! Your children will experience the High Holidays under the care of warm and knowledgeable staff.<br />
<br />
For ages 3 and up.</span></div>
</div> </div></li><li class="form-line" id="id_3"><div class="form-label-left" id="label_3"><label for="input_3"> Family name<span class="form-required">*</span> </label><label class="label-message" for="input_3"> </label></div><div id="cid_3" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_3" name="q3_familyName3" size="20" value="" /> </div></li><li class="form-line" id="id_16"><div class="form-label-left" id="label_16"><label for="input_16"> Number of children joining:<span class="form-required">*</span> </label><label class="label-message" for="input_16"> $36/child</label></div><div id="cid_16" class="form-input"> <input type="number" class="form-number-input  form-textbox validate[required]" id="input_16" name="q16_number" style="width:60px" size="5" value="" data-type="input-number" autocomplete="nope" min="0" data-numbermin="0" /> </div></li><li id="cid_4" class="form-input-wide"> <div class="form-header-group"><h3 id="header_4" class="form-header">Junior Congregation Information</h3></div> </li><li class="form-line" id="id_5"><div class="form-label-left" id="label_5"><label for="input_5"> 1. Child's First Name<span class="form-required">*</span> </label><label class="label-message" for="input_5"> </label></div><div id="cid_5" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_5" name="q5_1Childs" size="20" value="" /> </div></li><li class="form-line" id="id_6"><div class="form-label-left" id="label_6"><label for="input_6"> Child's Age<span class="form-required">*</span> </label><label class="label-message" for="input_6"> </label></div><div id="cid_6" class="form-input"> <input type="text" class=" form-textbox validate[required]" data-type="input-textbox" id="input_6" name="q6_childsAge" size="4" value="" /> </div></li><li class="form-line" id="id_7"><div class="form-label-left" id="label_7"><label for="input_7"> 2. Child's First Name </label><label class="label-message" for="input_7"> </label></div><div id="cid_7" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_7" name="q7_2Childs7" size="20" value="" /> </div></li><li class="form-line" id="id_8"><div class="form-label-left" id="label_8"><label for="input_8"> Child's Age </label><label class="label-message" for="input_8"> </label></div><div id="cid_8" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_8" name="q8_childsAge8" size="4" value="" /> </div></li><li class="form-line" id="id_9"><div class="form-label-left" id="label_9"><label for="input_9"> 3. Child's First Name </label><label class="label-message" for="input_9"> </label></div><div id="cid_9" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_9" name="q9_3Childs" size="20" value="" /> </div></li><li class="form-line" id="id_12"><div class="form-label-left" id="label_12"><label for="input_12"> Child's Age </label><label class="label-message" for="input_12"> </label></div><div id="cid_12" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_12" name="q12_childsAge12" size="4" value="" /> </div></li><li class="form-line" id="id_11"><div class="form-label-left" id="label_11"><label for="input_11"> 4. Child's First Name </label><label class="label-message" for="input_11"> </label></div><div id="cid_11" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_11" name="q11_4Childs" size="20" value="" /> </div></li><li class="form-line" id="id_10"><div class="form-label-left" id="label_10"><label for="input_10"> Child's Age </label><label class="label-message" for="input_10"> </label></div><div id="cid_10" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_10" name="q10_childsAge10" size="4" value="" /> </div></li><li class="form-line" id="id_13"><div class="form-label-left" id="label_13"><label for="input_13"> 5. Child's First Name </label><label class="label-message" for="input_13"> </label></div><div id="cid_13" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_13" name="q13_5Childs" size="20" value="" /> </div></li><li class="form-line" id="id_14"><div class="form-label-left" id="label_14"><label for="input_14"> Child's Age </label><label class="label-message" for="input_14"> </label></div><div id="cid_14" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_14" name="q14_childsAge14" size="4" value="" /> </div></li><li class="form-line" id="id_15"><div class="form-label-left" id="label_15"><label for="input_15"> Any Allergies? </label><label class="label-message" for="input_15"> </label></div><div id="cid_15" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_15" name="q15_Childs15" size="50" value="" /> </div></li><li id="cid_19" class="form-input-wide"> <div class="form-header-group"><h2 id="header_19" class="form-header">High Holiday Donation:</h2><div id="subHeader_19" class="form-subHeader">Please consider making a High Holiday dedication. Your support will enable us to cover the High Holiday expenses and continue to provide inspiration for the Jewish community.  *All donations over $500 will be listed on our Sponsorship Board</div></div> </li><li class="form-line" id="id_20"><div class="form-label-left" id="label_20"><label for="input_20"> Sponsorship Opportunities: </label><label class="label-message" for="input_20"> </label></div><div id="cid_20" class="form-input"> <div class="form-multiple-column" data-columns="3"><span class="form-radio-item"><input type="radio" class="form-radio" id="input_20_0" name="q20_input20" value="180" /><label for="input_20_0"><span>$180</span></label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio" id="input_20_1" name="q20_input20" value="360" /><label for="input_20_1"><span>$360</span></label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio" id="input_20_2" name="q20_input20" value="500" /><label for="input_20_2"><span>$500</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_20_3" name="q20_input20" value="750" /><label for="input_20_3"><span>$750</span></label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio" id="input_20_4" name="q20_input20" value="1000" /><label for="input_20_4"><span>$1000</span></label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio" id="input_20_5" name="q20_input20" value="1800" /><label for="input_20_5"><span>$1800</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_20_6" name="q20_input20" value="3600" /><label for="input_20_6"><span>$3600</span></label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio" id="input_20_7" name="q20_input20" value="5000" /><label for="input_20_7"><span>$5000</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio-other form-radio" name="q20_input20" id="other_20" value="" /><span><input type="number" min="1" class="form-radio-other-input form-textbox" onkeypress="validateNumber(event)" name="q20_input20[other]" data-otherhint="Other" size="15" id="input_20" disabled="disabled" /></span><br /></span></div> </div></li><li class="form-line" id="id_17"><div class="form-label-left" id="label_17"><label for="input_17"> Total </label></div><div id="cid_17" class="form-input"> <div id="total_amount">$0.00 </div> </div></li><li class="form-line" id="id_18"><div class="form-label-left" id="label_18"><label for="input_18"> Payment </label><label class="label-message" for="input_18"> </label></div><div id="cid_18" 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[paymentMethod] form-radio" type="radio" id="input_18_creditCard" name="q18_payment[payment_method]" value="creditCard" onclick="BuildSource.creditCard(this)" /><label for="input_18_creditCard">Credit Card</label> </span><span class="form-radio-item"><input class="paymentMethod form-radio validate[paymentMethod] form-radio" type="radio" id="input_18_other" name="q18_payment[payment_method]" value="other" onclick="BuildSource.other(this)" /><label for="input_18_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, Discover</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 class="cc-icon discover-icon"></div></div><input type="hidden" name="q18_payment[cc_type]" id="input_18_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[visible, creditcard]" type="text" name="q18_payment[cc_number]" id="input_18_cc_number" autocomplete="cc-number" size="20" />  <label class="form-sub-label" for="input_18_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[visible]" type="text" name="q18_payment[cc_ccv]" id="input_18_cc_ccv" autocomplete="cc-csc" size="6" />  <label class="form-sub-label" for="input_18_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[visible]" type="text" name="q18_payment[cc_nameOnCard]" id="input_18_cc_nameOnCard" autocomplete="cc-name" size="33" />  <label class="form-sub-label" for="input_18_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[visible]" name="q18_payment[cc_exp_month]" id="input_18_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_18_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[visible]" name="q18_payment[cc_exp_year]" id="input_18_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_18_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">Checks should be written out to Adult Education at Chabad &amp; mailed to Project Rosh, 41 Heather Drive, Manalapan, NJ 07726</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 form-address-line" type="text" name="q18_payment[addr_line1]" id="input_18_addr_line1" autocomplete="billing address-line1" />  <label class="form-sub-label" for="input_18_addr_line1" id="sublabel_18_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 form-address-city" type="text" name="q18_payment[city]" id="input_18_city" autocomplete="billing address-level2" />  <label class="form-sub-label" for="input_18_city" id="sublabel_18_city">City</label></span></td><td><span class="form-sub-label-container"><input class="form-textbox form-address-state" type="text" name="q18_payment[state]" id="input_18_state" autocomplete="billing address-level1" />  <label class="form-sub-label" for="input_18_state" id="sublabel_18_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 form-address-postal" type="text" name="q18_payment[postal]" id="input_18_postal" size="10" autocomplete="billing postal-code" />  <label class="form-sub-label" for="input_18_postal" id="sublabel_18_postal">Postal / Zip Code</label></span></td><td><span class="form-sub-label-container"><select class="form-dropdown form-address-country" name="q18_payment[country]" id="input_18_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 value="Grenada">Grenada</option><option value="Guadeloupe">Guadeloupe</option><option value="Guam">Guam</option><option value="Guatemala">Guatemala</option><option value="Guernsey">Guernsey</option><option value="Guinea">Guinea</option><option value="Guinea-Bissau">Guinea-Bissau</option><option value="Guyana">Guyana</option><option value="Haiti">Haiti</option><option value="Honduras">Honduras</option><option value="Hong Kong">Hong Kong</option><option value="Hungary">Hungary</option><option value="Iceland">Iceland</option><option value="India">India</option><option value="Indonesia">Indonesia</option><option value="Iran">Iran</option><option value="Iraq">Iraq</option><option value="Ireland">Ireland</option><option value="Israel">Israel</option><option value="Italy">Italy</option><option value="Jamaica">Jamaica</option><option value="Japan">Japan</option><option value="Jersey">Jersey</option><option value="Jordan">Jordan</option><option value="Kazakhstan">Kazakhstan</option><option value="Kenya">Kenya</option><option value="Kiribati">Kiribati</option><option value="North Korea">North Korea</option><option value="South Korea">South Korea</option><option value="Kosovo">Kosovo</option><option value="Kuwait">Kuwait</option><option value="Kyrgyzstan">Kyrgyzstan</option><option value="Laos">Laos</option><option value="Latvia">Latvia</option><option value="Lebanon">Lebanon</option><option value="Lesotho">Lesotho</option><option value="Liberia">Liberia</option><option value="Libya">Libya</option><option value="Liechtenstein">Liechtenstein</option><option value="Lithuania">Lithuania</option><option value="Luxembourg">Luxembourg</option><option value="Macau">Macau</option><option value="Macedonia">Macedonia</option><option value="Madagascar">Madagascar</option><option value="Malawi">Malawi</option><option value="Malaysia">Malaysia</option><option value="Maldives">Maldives</option><option value="Mali">Mali</option><option value="Malta">Malta</option><option value="Marshall Islands">Marshall Islands</option><option value="Martinique">Martinique</option><option value="Mauritania">Mauritania</option><option value="Mauritius">Mauritius</option><option value="Mayotte">Mayotte</option><option value="Mexico">Mexico</option><option value="Micronesia">Micronesia</option><option value="Moldova">Moldova</option><option value="Monaco">Monaco</option><option value="Mongolia">Mongolia</option><option value="Montenegro">Montenegro</option><option 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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 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