{"id":475,"date":"2019-01-04T23:54:08","date_gmt":"2019-01-04T23:54:08","guid":{"rendered":"https:\/\/jerusalemfieldschool.com\/?page_id=475"},"modified":"2019-04-01T16:46:44","modified_gmt":"2019-04-01T16:46:44","slug":"application-form","status":"publish","type":"page","link":"https:\/\/jerusalemfieldschool.com\/application-form","title":{"rendered":"Short Term Program Application Form"},"content":{"rendered":"\n                <div class='gf_browser_chrome gform_wrapper' id='gform_wrapper_6' style='display:none'><div id='gf_6' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_6' id='gform_6'  action='\/wp-json\/wp\/v2\/pages\/475#gf_6'>\n                        <div class='gform_heading'>\n                            <h3 class='gform_title'>JFS Fall 2020 Application<\/h3>\n                            <span class='gform_description'><\/span>\n                        <\/div>\n        <div id='gf_progressbar_wrapper_6' class='gf_progressbar_wrapper'>\n            <h3 class='gf_progressbar_title'>Step 1 of 5 - Basic Information\n        <\/h3>\n            <div class='gf_progressbar'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_20' style='width:20%;'><span>20%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform_body'><div id='gform_page_6_1' class='gform_page' >\n                                    <div class='gform_page_fields'><ul id='gform_fields_6' class='gform_fields top_label form_sublabel_below description_below'><li id='field_6_113'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Select the programs for which you would like to apply<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_113'><li class='gchoice_6_113_1'>\n\t\t\t\t\t\t\t\t<input name='input_113.1' type='checkbox'  value='JFS Tour (Oct 21 - Nov 2) - 2850 USD'  id='choice_6_113_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_113_1' id='label_6_113_1'>JFS Tour (Oct 21 - Nov 2) - 2850 USD<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_6_113_2'>\n\t\t\t\t\t\t\t\t<input name='input_113.2' type='checkbox'  value='Dig at Et Tell Week 1 (Nov 2 - 9) - 950 USD'  id='choice_6_113_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_113_2' id='label_6_113_2'>Dig at Et Tell Week 1 (Nov 2 - 9) - 950 USD<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_6_113_3'>\n\t\t\t\t\t\t\t\t<input name='input_113.3' type='checkbox'  value='Dig at Et Tell Week 2 (Nov 9 - 16) - 950 USD'  id='choice_6_113_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_113_3' id='label_6_113_3'>Dig at Et Tell Week 2 (Nov 9 - 16) - 950 USD<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id='field_6_112'  class='gfield gf_invisible gfield_price gfield_price_6_112 gfield_product_6_112 field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_6_112_1' >JFS Tour - Fall 2020<\/label><div class='ginput_container ginput_container_singleproduct'>\n\t\t\t\t\t<input type='hidden' name='input_112.1' value='JFS Tour - Fall 2020' class='gform_hidden' \/>\n\t\t\t\t\t<span class='ginput_product_price_label'>Price:<\/span> <span class='ginput_product_price' id='input_6_112'>$2,850.00<\/span>\n\t\t\t\t\t<input type='hidden' name='input_112.2' id='ginput_base_price_6_112' class='gform_hidden' value='$2,850.00'\/>\n\t\t\t\t\t<input type='hidden' name='input_112.3' value='1' class='ginput_quantity_6_112 gform_hidden' \/>\n\t\t\t\t<\/div><\/li><li id='field_6_114'  class='gfield gf_invisible gfield_price gfield_price_6_114 gfield_product_6_114 field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_6_114_1' >Et Tell Excavation Week 1 (Nov 2 - 9)<\/label><div class='ginput_container ginput_container_singleproduct'>\n\t\t\t\t\t<input type='hidden' name='input_114.1' value='Et Tell Excavation Week 1 (Nov 2 - 9)' class='gform_hidden' \/>\n\t\t\t\t\t<span class='ginput_product_price_label'>Price:<\/span> <span class='ginput_product_price' id='input_6_114'>$950.00<\/span>\n\t\t\t\t\t<input type='hidden' name='input_114.2' id='ginput_base_price_6_114' class='gform_hidden' value='$950.00'\/>\n\t\t\t\t\t<input type='hidden' name='input_114.3' value='1' class='ginput_quantity_6_114 gform_hidden' \/>\n\t\t\t\t<\/div><\/li><li id='field_6_116'  class='gfield gf_invisible gfield_price gfield_price_6_116 gfield_product_6_116 field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_6_116_1' >Et Tell Excavation Week 2 - (Nov 9 - 16)<\/label><div class='ginput_container ginput_container_singleproduct'>\n\t\t\t\t\t<input type='hidden' name='input_116.1' value='Et Tell Excavation Week 2 - (Nov 9 - 16)' class='gform_hidden' \/>\n\t\t\t\t\t<span class='ginput_product_price_label'>Price:<\/span> <span class='ginput_product_price' id='input_6_116'>$950.00<\/span>\n\t\t\t\t\t<input type='hidden' name='input_116.2' id='ginput_base_price_6_116' class='gform_hidden' value='$950.00'\/>\n\t\t\t\t\t<input type='hidden' name='input_116.3' value='1' class='ginput_quantity_6_116 gform_hidden' \/>\n\t\t\t\t<\/div><\/li><li id='field_6_115'  class='gfield gfield_price gfield_price_6_ gfield_total gfield_total_6_ field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_6_115' >Total<\/label><div class='ginput_container ginput_container_total'>\n\t\t\t\t\t\t<span class='ginput_total ginput_total_6' aria-live='polite'>$0.00<\/span>\n\t\t\t\t\t\t<input type='hidden' name='input_115' id='input_6_115' class='gform_hidden'\/>\n\t\t\t\t\t<\/div><div class='gfield_description' id='gfield_description_6_115'>* You will receive payment information upon acceptance of application<\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer'>\n                         <input type='button' id='gform_next_button_6_107' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_6\").val(\"2\");  jQuery(\"#gform_6\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_6\").val(\"2\");  jQuery(\"#gform_6\").trigger(\"submit\",[true]); } ' \/> <a href='javascript:void(0);' id='gform_save_6_2_link' class='gform_save_link'  onclick='if(window[\"gf_submitting_6\"]){return false;}  window[\"gf_submitting_6\"]=true; jQuery(\"#gform_save_6\").val(1); jQuery(\"#gform_6\").trigger(\"submit\",[true]);' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_6\"]){return false;} window[\"gf_submitting_6\"]=true; jQuery(\"#gform_save_6\").val(1); jQuery(\"#gform_6\").trigger(\"submit\",[true]); }'>Save and Continue Later<\/a>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_6_2' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_6_2' class='gform_fields top_label form_sublabel_below description_below'><li id='field_6_102'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Personal Details<\/h2><\/li><li id='field_6_97'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex'  >Name<span class='gfield_required'>*<\/span><\/label><div class='ginput_complex ginput_container no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name' id='input_6_97'>\n                            \n                            <span id='input_6_97_3_container' class='name_first' >\n                                                    <input type='text' name='input_97.3' id='input_6_97_3' value='' aria-label='First name'   aria-required=\"true\" aria-invalid=\"false\" \/>\n                                                    <label for='input_6_97_3' >First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_6_97_6_container' class='name_last' >\n                                                    <input type='text' name='input_97.6' id='input_6_97_6' value='' aria-label='Last name'   aria-required=\"true\" aria-invalid=\"false\" \/>\n                                                    <label for='input_6_97_6' >Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id='field_6_35'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_6_35' >Date of Birth<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_35' id='input_6_35' type='text' value='' class='datepicker medium mdy datepicker_no_icon'    aria-describedby='input_6_35_date_format' \/>\n                            <span id='input_6_35_date_format' class='screen-reader-text'>Date Format: MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_35' class='gform_hidden' value='https:\/\/jerusalemfieldschool.com\/wp-content\/plugins\/gravityforms\/images\/calendar.png'\/><\/li><li id='field_6_36'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_6_36' >Country of Citizenship<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_6_36' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\" \/><\/div><\/li><li id='field_6_3'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label gfield_label_before_complex'  >Address<span class='gfield_required'>*<\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address' id='input_6_3' >\n                         <span class='ginput_full address_line_1' id='input_6_3_1_container' >\n                                        <input type='text' name='input_3.1' id='input_6_3_1' value=''    aria-required=\"true\"\/>\n                                        <label for='input_6_3_1' id='input_6_3_1_label' >Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2' id='input_6_3_2_container' >\n                                        <input type='text' name='input_3.2' id='input_6_3_2' value=''   \/>\n                                        <label for='input_6_3_2' id='input_6_3_2_label' >Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city' id='input_6_3_3_container' >\n                                    <input type='text' name='input_3.3' id='input_6_3_3' value=''    aria-required=\"true\"\/>\n                                    <label for='input_6_3_3' id='input_6_3_3_label' >City<\/label>\n                                 <\/span><span class='ginput_right address_state' id='input_6_3_4_container' >\n                                        <input type='text' name='input_3.4' id='input_6_3_4' value=''      aria-required=\"true\"\/>\n                                        <label for='input_6_3_4' id='input_6_3_4_label' >State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip' id='input_6_3_5_container' >\n                                    <input type='text' name='input_3.5' id='input_6_3_5' value=''    aria-required=\"true\"\/>\n                                    <label for='input_6_3_5' id='input_6_3_5_label' >ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_right address_country' id='input_6_3_6_container' >\n                                        <select name='input_3.6' id='input_6_3_6'   aria-required=\"true\"><option value='' ><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/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='Antarctica' >Antarctica<\/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='Bahamas' >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='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/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='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Congo, Republic of the' >Congo, Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/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 (Swaziland)' >Eswatini (Swaziland)<\/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 Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >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='Heard and McDonald Islands' >Heard and McDonald Islands<\/option><option value='Holy See' >Holy See<\/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='Isle of Man' >Isle of Man<\/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='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/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 value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Korea' >North Korea<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/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' >Pitcairn<\/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='R\u00e9union' >R\u00e9union<\/option><option value='Romania' >Romania<\/option><option value='Russia' >Russia<\/option><option value='Rwanda' >Rwanda<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/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='Sint Maarten' >Sint Maarten<\/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='South Africa' >South Africa<\/option><option value='South Georgia' >South Georgia<\/option><option value='South Korea' >South Korea<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen Islands' >Svalbard and Jan Mayen Islands<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria' >Syria<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania' >Tanzania<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkey' >Turkey<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' selected='selected'>United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vietnam' >Vietnam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><\/select>\n                                        <label for='input_6_3_6' id='input_6_3_6_label' >Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id='field_6_4'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_6_4' >Phone<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_4' id='input_6_4' type='text' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/li><li id='field_6_2'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_6_2' >Email<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_2' id='input_6_2' type='text' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\" \/>\n                        <\/div><\/li><li id='field_6_39'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_6_39' >Please upload a passport style photograph<\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='104857600' \/><input name='input_39' id='input_6_39' type='file' class='medium' aria-describedby='validation_message_6_39 live_validation_message_6_39 extensions_message_6_39' onchange='javascript:gformValidateFileSize( this, 104857600 );'  \/><span id='extensions_message_6_39' class='screen-reader-text'><\/span><div class='validation_message' id='live_validation_message_6_39'><\/div><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer'>\n                        <input type='button' id='gform_previous_button_6_11' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_6\").val(\"1\");  jQuery(\"#gform_6\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_6\").val(\"1\");  jQuery(\"#gform_6\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_6_11' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_6\").val(\"3\");  jQuery(\"#gform_6\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_6\").val(\"3\");  jQuery(\"#gform_6\").trigger(\"submit\",[true]); } ' \/> <a href='javascript:void(0);' id='gform_save_6_3_link' class='gform_save_link'  onclick='if(window[\"gf_submitting_6\"]){return false;}  window[\"gf_submitting_6\"]=true; jQuery(\"#gform_save_6\").val(1); jQuery(\"#gform_6\").trigger(\"submit\",[true]);' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_6\"]){return false;} window[\"gf_submitting_6\"]=true; jQuery(\"#gform_save_6\").val(1); jQuery(\"#gform_6\").trigger(\"submit\",[true]); }'>Save and Continue Later<\/a>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_6_3' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_6_3' class='gform_fields top_label form_sublabel_below description_below'><li id='field_6_16'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Academic Information<\/h2><\/li><li id='field_6_14'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_6_14' >Name of academic institution currently attending or last attended (Name, State, Country)<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_6_14' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\" \/><\/div><\/li><li id='field_6_21'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_6_21' >Year Completed<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_21' id='input_6_21' type='text' value='' class='datepicker medium mdy datepicker_with_icon'    aria-describedby='input_6_21_date_format' \/>\n                            <span id='input_6_21_date_format' class='screen-reader-text'>Date Format: MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_21' class='gform_hidden' value='https:\/\/jerusalemfieldschool.com\/wp-content\/plugins\/gravityforms\/images\/calendar.png'\/><div class='gfield_description' id='gfield_description_6_21'>Please leave blank if still enrolled<\/div><\/li><li id='field_6_15'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_6_15' >Course of Studies<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_textarea'><div id=\"wp-input_6_15-wrap\" class=\"wp-core-ui wp-editor-wrap tmce-active\"><link rel='stylesheet' id='dashicons-css'  href='https:\/\/jerusalemfieldschool.com\/wp-includes\/css\/dashicons.min.css?ver=5.9.7' type='text\/css' media='all' \/>\n<link rel='stylesheet' id='editor-buttons-css'  href='https:\/\/jerusalemfieldschool.com\/wp-includes\/css\/editor.min.css?ver=5.9.7' type='text\/css' media='all' \/>\n<div id=\"wp-input_6_15-editor-container\" class=\"wp-editor-container\"><textarea class=\"medium wp-editor-area\" style=\"height: 180px\" autocomplete=\"off\" cols=\"40\" name=\"input_15\" id=\"input_6_15\"><\/textarea><\/div>\n<\/div>\n\n<\/div><div class='gfield_description' id='gfield_description_6_15'>Please briefly describe area of study, number of credits, or degree earned.<\/div><\/li><li id='field_6_43'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Other institutions?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_43'><li class='gchoice_6_43_0'><input name='input_43' type='radio' value='Yes'  id='choice_6_43_0'    \/><label for='choice_6_43_0' id='label_6_43_0'>Yes<\/label><\/li><li class='gchoice_6_43_1'><input name='input_43' type='radio' value='No'  id='choice_6_43_1'    \/><label for='choice_6_43_1' id='label_6_43_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_6_17'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Academic Institution #2<\/h2><\/li><li id='field_6_19'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_6_19' >Name of Academic Institution<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_6_19' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\" \/><\/div><\/li><li id='field_6_12'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_6_12' >Year Completed<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_12' id='input_6_12' type='text' value='' class='datepicker medium mdy datepicker_with_icon'    aria-describedby='input_6_12_date_format' \/>\n                            <span id='input_6_12_date_format' class='screen-reader-text'>Date Format: MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_12' class='gform_hidden' value='https:\/\/jerusalemfieldschool.com\/wp-content\/plugins\/gravityforms\/images\/calendar.png'\/><div class='gfield_description' id='gfield_description_6_12'>Please leave blank if still enrolled<\/div><\/li><li id='field_6_24'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_6_24' >Course of Study<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_textarea'><div id=\"wp-input_6_24-wrap\" class=\"wp-core-ui wp-editor-wrap tmce-active\"><div id=\"wp-input_6_24-editor-container\" class=\"wp-editor-container\"><textarea class=\"medium wp-editor-area\" style=\"height: 180px\" autocomplete=\"off\" cols=\"40\" name=\"input_24\" id=\"input_6_24\"><\/textarea><\/div>\n<\/div>\n\n<\/div><div class='gfield_description' id='gfield_description_6_24'>Please briefly describe area of study, number of credits, or degree earned.<\/div><\/li><li id='field_6_32'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Other Institutions?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_32'><li class='gchoice_6_32_0'><input name='input_32' type='radio' value='Yes'  id='choice_6_32_0'    \/><label for='choice_6_32_0' id='label_6_32_0'>Yes<\/label><\/li><li class='gchoice_6_32_1'><input name='input_32' type='radio' value='No'  id='choice_6_32_1'    \/><label for='choice_6_32_1' id='label_6_32_1'>No<\/label><\/li><\/ul><\/div><\/li><li id='field_6_18'  class='gfield gsection field_sublabel_below field_description_below gfield_visibility_visible' ><h2 class='gsection_title'>Academic Institution #3<\/h2><\/li><li id='field_6_20'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_6_20' >Name of Academic Institution<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_6_20' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\" \/><\/div><\/li><li id='field_6_22'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_6_22' >Year Completed<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_22' id='input_6_22' type='text' value='' class='datepicker medium mdy datepicker_with_icon'    aria-describedby='input_6_22_date_format' \/>\n                            <span id='input_6_22_date_format' class='screen-reader-text'>Date Format: MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_22' class='gform_hidden' value='https:\/\/jerusalemfieldschool.com\/wp-content\/plugins\/gravityforms\/images\/calendar.png'\/><div class='gfield_description' id='gfield_description_6_22'>Please leave blank if still enrolled.<\/div><\/li><li id='field_6_26'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_6_26' >Course of Study<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_textarea'><div id=\"wp-input_6_26-wrap\" class=\"wp-core-ui wp-editor-wrap tmce-active\"><div id=\"wp-input_6_26-editor-container\" class=\"wp-editor-container\"><textarea class=\"medium wp-editor-area\" style=\"height: 180px\" autocomplete=\"off\" cols=\"40\" name=\"input_26\" id=\"input_6_26\"><\/textarea><\/div>\n<\/div>\n\n<\/div><div class='gfield_description' id='gfield_description_6_26'>Please briefly describe area of study, number of credits, or degree earned.<\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer'>\n                        <input type='button' id='gform_previous_button_6_51' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_6\").val(\"2\");  jQuery(\"#gform_6\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_6\").val(\"2\");  jQuery(\"#gform_6\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_6_51' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_6\").val(\"4\");  jQuery(\"#gform_6\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_6\").val(\"4\");  jQuery(\"#gform_6\").trigger(\"submit\",[true]); } ' \/> <a href='javascript:void(0);' id='gform_save_6_4_link' class='gform_save_link'  onclick='if(window[\"gf_submitting_6\"]){return false;}  window[\"gf_submitting_6\"]=true; jQuery(\"#gform_save_6\").val(1); jQuery(\"#gform_6\").trigger(\"submit\",[true]);' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_6\"]){return false;} window[\"gf_submitting_6\"]=true; jQuery(\"#gform_save_6\").val(1); jQuery(\"#gform_6\").trigger(\"submit\",[true]); }'>Save and Continue Later<\/a>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_6_4' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_6_4' class='gform_fields top_label form_sublabel_below description_below'><li id='field_6_71'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Please identify any pre-existing medical conditions.<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_71'><li class='gchoice_6_71_1'>\n\t\t\t\t\t\t\t\t<input name='input_71.1' type='checkbox'  value='Allergies'  id='choice_6_71_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_71_1' id='label_6_71_1'>Allergies<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_6_71_2'>\n\t\t\t\t\t\t\t\t<input name='input_71.2' type='checkbox'  value='Inflammatory Disease'  id='choice_6_71_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_71_2' id='label_6_71_2'>Inflammatory Disease<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_6_71_3'>\n\t\t\t\t\t\t\t\t<input name='input_71.3' type='checkbox'  value='Amoebic Dysentery'  id='choice_6_71_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_71_3' id='label_6_71_3'>Amoebic Dysentery<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_6_71_4'>\n\t\t\t\t\t\t\t\t<input name='input_71.4' type='checkbox'  value='Asthma'  id='choice_6_71_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_71_4' id='label_6_71_4'>Asthma<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_6_71_5'>\n\t\t\t\t\t\t\t\t<input name='input_71.5' type='checkbox'  value='Diabetes'  id='choice_6_71_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_71_5' id='label_6_71_5'>Diabetes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_6_71_6'>\n\t\t\t\t\t\t\t\t<input name='input_71.6' type='checkbox'  value='Epilepsy'  id='choice_6_71_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_71_6' id='label_6_71_6'>Epilepsy<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_6_71_7'>\n\t\t\t\t\t\t\t\t<input name='input_71.7' type='checkbox'  value='Foot or Leg Conditions'  id='choice_6_71_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_71_7' id='label_6_71_7'>Foot or Leg Conditions<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_6_71_8'>\n\t\t\t\t\t\t\t\t<input name='input_71.8' type='checkbox'  value='Gastro-Intestinal Disease'  id='choice_6_71_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_71_8' id='label_6_71_8'>Gastro-Intestinal Disease<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_6_71_9'>\n\t\t\t\t\t\t\t\t<input name='input_71.9' type='checkbox'  value='Hepatitus'  id='choice_6_71_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_71_9' id='label_6_71_9'>Hepatitus<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_6_71_11'>\n\t\t\t\t\t\t\t\t<input name='input_71.11' type='checkbox'  value='High Blood Pressure'  id='choice_6_71_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_71_11' id='label_6_71_11'>High Blood Pressure<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_6_71_12'>\n\t\t\t\t\t\t\t\t<input name='input_71.12' type='checkbox'  value='HIV\/AIDS'  id='choice_6_71_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_71_12' id='label_6_71_12'>HIV\/AIDS<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_6_71_13'>\n\t\t\t\t\t\t\t\t<input name='input_71.13' type='checkbox'  value='Hypertension'  id='choice_6_71_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_71_13' id='label_6_71_13'>Hypertension<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_6_71_14'>\n\t\t\t\t\t\t\t\t<input name='input_71.14' type='checkbox'  value='Hypoglycemia'  id='choice_6_71_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_71_14' id='label_6_71_14'>Hypoglycemia<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_6_71_15'>\n\t\t\t\t\t\t\t\t<input name='input_71.15' type='checkbox'  value='Kidney Condition'  id='choice_6_71_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_71_15' id='label_6_71_15'>Kidney Condition<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_6_71_16'>\n\t\t\t\t\t\t\t\t<input name='input_71.16' type='checkbox'  value='Learning Disability'  id='choice_6_71_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_71_16' id='label_6_71_16'>Learning Disability<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_6_71_17'>\n\t\t\t\t\t\t\t\t<input name='input_71.17' type='checkbox'  value='Malaria'  id='choice_6_71_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_71_17' id='label_6_71_17'>Malaria<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_6_71_18'>\n\t\t\t\t\t\t\t\t<input name='input_71.18' type='checkbox'  value='Mental Health \/ Disorder'  id='choice_6_71_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_71_18' id='label_6_71_18'>Mental Health \/ Disorder<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_6_71_19'>\n\t\t\t\t\t\t\t\t<input name='input_71.19' type='checkbox'  value='Migraine Headaches'  id='choice_6_71_19'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_71_19' id='label_6_71_19'>Migraine Headaches<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_6_71_21'>\n\t\t\t\t\t\t\t\t<input name='input_71.21' type='checkbox'  value='Mononucleosis'  id='choice_6_71_21'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_71_21' id='label_6_71_21'>Mononucleosis<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_6_71_22'>\n\t\t\t\t\t\t\t\t<input name='input_71.22' type='checkbox'  value='Nervous Disorder'  id='choice_6_71_22'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_71_22' id='label_6_71_22'>Nervous Disorder<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_6_71_23'>\n\t\t\t\t\t\t\t\t<input name='input_71.23' type='checkbox'  value='Paralysis'  id='choice_6_71_23'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_71_23' id='label_6_71_23'>Paralysis<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_6_71_24'>\n\t\t\t\t\t\t\t\t<input name='input_71.24' type='checkbox'  value='Pneumonia'  id='choice_6_71_24'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_71_24' id='label_6_71_24'>Pneumonia<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_6_71_25'>\n\t\t\t\t\t\t\t\t<input name='input_71.25' type='checkbox'  value='Rheumatic Fever'  id='choice_6_71_25'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_71_25' id='label_6_71_25'>Rheumatic Fever<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_6_71_26'>\n\t\t\t\t\t\t\t\t<input name='input_71.26' type='checkbox'  value='Substance Abuse'  id='choice_6_71_26'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_71_26' id='label_6_71_26'>Substance Abuse<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_6_71_27'>\n\t\t\t\t\t\t\t\t<input name='input_71.27' type='checkbox'  value='Tuberculosis'  id='choice_6_71_27'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_71_27' id='label_6_71_27'>Tuberculosis<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id='field_6_72'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Have you ever been under the care of a mental health physician?<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_72'><li class='gchoice_6_72_1'>\n\t\t\t\t\t\t\t\t<input name='input_72.1' type='checkbox'  value='Yes'  id='choice_6_72_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_72_1' id='label_6_72_1'>Yes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_6_72_2'>\n\t\t\t\t\t\t\t\t<input name='input_72.2' type='checkbox'  value='No'  id='choice_6_72_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_72_2' id='label_6_72_2'>No<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id='field_6_78'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_6_78' >Please explain.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_78' id='input_6_78' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id='field_6_73'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Are you receiving medication or physician&#039;s care for any medical conditions?<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_73'><li class='gchoice_6_73_1'>\n\t\t\t\t\t\t\t\t<input name='input_73.1' type='checkbox'  value='Yes'  id='choice_6_73_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_73_1' id='label_6_73_1'>Yes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_6_73_2'>\n\t\t\t\t\t\t\t\t<input name='input_73.2' type='checkbox'  value='No'  id='choice_6_73_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_73_2' id='label_6_73_2'>No<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id='field_6_79'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_6_79' >Please explain.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_79' id='input_6_79' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id='field_6_76'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Do you have any previous history of substance abuse or mental illness?<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_76'><li class='gchoice_6_76_1'>\n\t\t\t\t\t\t\t\t<input name='input_76.1' type='checkbox'  value='Yes'  id='choice_6_76_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_76_1' id='label_6_76_1'>Yes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_6_76_2'>\n\t\t\t\t\t\t\t\t<input name='input_76.2' type='checkbox'  value='No'  id='choice_6_76_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_76_2' id='label_6_76_2'>No<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id='field_6_80'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_6_80' >Please explain.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_80' id='input_6_80' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id='field_6_75'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Are you allergic to any medication or foods?<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_75'><li class='gchoice_6_75_1'>\n\t\t\t\t\t\t\t\t<input name='input_75.1' type='checkbox'  value='Yes'  id='choice_6_75_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_75_1' id='label_6_75_1'>Yes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_6_75_2'>\n\t\t\t\t\t\t\t\t<input name='input_75.2' type='checkbox'  value='No'  id='choice_6_75_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_75_2' id='label_6_75_2'>No<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id='field_6_81'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_6_81' >Please explain.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_81' id='input_6_81' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id='field_6_74'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Do you have any dietary restrictions?<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_74'><li class='gchoice_6_74_1'>\n\t\t\t\t\t\t\t\t<input name='input_74.1' type='checkbox'  value='Yes'  id='choice_6_74_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_74_1' id='label_6_74_1'>Yes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_6_74_2'>\n\t\t\t\t\t\t\t\t<input name='input_74.2' type='checkbox'  value='No'  id='choice_6_74_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_74_2' id='label_6_74_2'>No<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id='field_6_85'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_6_85' >Please explain.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_85' id='input_6_85' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id='field_6_77'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Are there any other medical conditions or information that we should know about you?<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_77'><li class='gchoice_6_77_1'>\n\t\t\t\t\t\t\t\t<input name='input_77.1' type='checkbox'  value='Yes'  id='choice_6_77_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_77_1' id='label_6_77_1'>Yes<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice_6_77_2'>\n\t\t\t\t\t\t\t\t<input name='input_77.2' type='checkbox'  value='No'  id='choice_6_77_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_77_2' id='label_6_77_2'>No<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id='field_6_83'  class='gfield field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label' for='input_6_83' >Please explain.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_83' id='input_6_83' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id='field_6_63'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >In Case of Emergency<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_consent'><input name='input_63.1' id='input_6_63_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gfield_consent_label\" for='input_6_63_1' >I give permission to a JFS representative in Israel to select a physician, to hospitalize, to secure proper treatment, to order injections, anasthesia, or surgery for me.<\/label><input type='hidden' name='input_63.2' value='I give permission to a JFS representative in Israel to select a physician, to hospitalize, to secure proper treatment, to order injections, anasthesia, or surgery for me.' class='gform_hidden' \/><input type='hidden' name='input_63.3' value='4' class='gform_hidden' \/><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer'>\n                        <input type='button' id='gform_previous_button_6_47' class='gform_previous_button button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_6\").val(\"3\");  jQuery(\"#gform_6\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_6\").val(\"3\");  jQuery(\"#gform_6\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_6_47' class='gform_next_button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_6\").val(\"5\");  jQuery(\"#gform_6\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_6\").val(\"5\");  jQuery(\"#gform_6\").trigger(\"submit\",[true]); } ' \/> <a href='javascript:void(0);' id='gform_save_6_5_link' class='gform_save_link'  onclick='if(window[\"gf_submitting_6\"]){return false;}  window[\"gf_submitting_6\"]=true; jQuery(\"#gform_save_6\").val(1); jQuery(\"#gform_6\").trigger(\"submit\",[true]);' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_6\"]){return false;} window[\"gf_submitting_6\"]=true; jQuery(\"#gform_save_6\").val(1); jQuery(\"#gform_6\").trigger(\"submit\",[true]); }'>Save and Continue Later<\/a>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_6_5' class='gform_page' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_6_5' class='gform_fields top_label form_sublabel_below description_below'><li id='field_6_46'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Liability Waver<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_consent'><input name='input_46.1' id='input_6_46_1' type='checkbox' value='1'  aria-describedby='gfield_consent_description_6_46' aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gfield_consent_label\" for='input_6_46_1' >I agree.<\/label><input type='hidden' name='input_46.2' value='I agree.' class='gform_hidden' \/><input type='hidden' name='input_46.3' value='4' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_6_46'>On my behalf and on behalf of my heirs, executors, personal representatives, contractees and employees, I hereby release and forever discharge Jerusalem Field School, their officers and employees from any claim for loss, death, disability, delay, or damage to person, property, or for accident or illness howsoever arising which may be suffered by me or by anyone claiming though me, during the period of, in consequence of, or in any way related to the work and\/or study undertaken by me in connection with my participation in this Project.<\/div><\/li><li id='field_6_50'  class='gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible' ><label class='gfield_label'  >Standard of Conduct<span class='gfield_required'>*<\/span><\/label><div class='ginput_container ginput_container_consent'><input name='input_50.1' id='input_6_50_1' type='checkbox' value='1'  aria-describedby='gfield_consent_description_6_50' aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gfield_consent_label\" for='input_6_50_1' >I agree.<\/label><input type='hidden' name='input_50.2' value='I agree.' class='gform_hidden' \/><input type='hidden' name='input_50.3' value='4' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_6_50'>The undersigned acknowledges the right of the Jerusalem Field School (JFS) to remove anyone from the program.  JFS does not assume any financial obligation to refund the cost of the program or any expenses associated with travel or lodging because of an early dismissal.<\/div><\/li>\n                            <\/ul><\/div>\n        <div class='gform_page_footer top_label'><input type='submit' id='gform_previous_button_6' class='gform_previous_button button' value='Previous'  onclick='if(window[\"gf_submitting_6\"]){return false;}  window[\"gf_submitting_6\"]=true;  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_6\"]){return false;} window[\"gf_submitting_6\"]=true;  jQuery(\"#gform_6\").trigger(\"submit\",[true]); }' \/> <input type='submit' id='gform_submit_button_6' class='gform_button button' value='Submit'  onclick='if(window[\"gf_submitting_6\"]){return false;}  window[\"gf_submitting_6\"]=true;  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_6\"]){return false;} window[\"gf_submitting_6\"]=true;  jQuery(\"#gform_6\").trigger(\"submit\",[true]); }' \/> <a href='javascript:void(0);' id='gform_save_6_footer_link' class='gform_save_link'  onclick='if(window[\"gf_submitting_6\"]){return false;}  window[\"gf_submitting_6\"]=true; jQuery(\"#gform_save_6\").val(1); jQuery(\"#gform_6\").trigger(\"submit\",[true]);' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_6\"]){return false;} window[\"gf_submitting_6\"]=true; jQuery(\"#gform_save_6\").val(1); jQuery(\"#gform_6\").trigger(\"submit\",[true]); }'>Save and Continue Later<\/a><input type='hidden' name='gform_ajax' value='form_id=6&amp;title=1&amp;description=1&amp;tabindex=0' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_6' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='6' \/>\n            <input type='hidden' class='gform_hidden' name='gform_save' id='gform_save_6' value='' \/>\n                             <input type='hidden' class='gform_hidden' name='gform_resume_token' id='gform_resume_token_6' value='' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_6' 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