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<form class="userform-form" action="" method="post" name="form_5677354" id="5677354" accept-charset="utf-8"><input type="hidden" name="formID" value="5677354" /><div class="form-all dir_ltr" dir="ltr"><ul class="form-section"><li class="form-line" id="id_10"><div id="cid_10" class="form-input-wide"> <div id="text_10" class="form-html"><p><strong>Adult </strong>| $100<br />
<strong>Child</strong> (2-12) | $50<br />
<strong>CYP</strong> | $50<br />
<strong>VIP Seat</strong> | $360<br />
<br />
<strong>Become a Shabbos Ambassador and host a VIP table of 10!</strong><br />
$3,600</p>
</div> </div></li><li class="form-line" id="id_9"><div class="form-label-left" id="label_9"><label for="input_9"> Shabbat Pledge </label><label class="label-message" for="input_9"> </label></div><div id="cid_9" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_9_0" name="q9_input9[]" value="I take on the Shabbos pledge to turn off my cell phone and use no other electronics for some or all of the 25 hours of Shabbat 24/6 (from Friday, January 5, at 4:24 p.m. until Shabbos, January 6, at 6:19 p.m.)." /><label id="label_input_9_0" for="input_9_0"><span>I take on the Shabbos pledge to turn off my cell phone and use no other electronics for some or all of the 25 hours of Shabbat 24/6 (from Friday, January 5, at 4:24 p.m. until Shabbos, January 6, at 6:19 p.m.).</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_1"><div class="form-label-left" id="label_1"><label for="input_1"> Full Name<span class="form-required">*</span> </label><label class="label-message" for="input_1"> </label></div><div id="cid_1" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q1_fullName[first]" id="first_1" autocomplete="given-name" />  <label class="form-sub-label" for="first_1" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q1_fullName[last]" id="last_1" autocomplete="family-name" />  <label class="form-sub-label" for="last_1" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_3"><div class="form-label-left" id="label_3"><label for="input_3"> Email<span class="form-required">*</span> </label><label class="label-message" for="input_3"> </label></div><div id="cid_3" class="form-input"> <input type="email" class=" form-textbox validate[required, Email]" id="input_3" name="q3_email" size="30" value="" autocomplete="email" /> </div></li><li class="form-line" id="id_4"><div class="form-label-left form-label-hidden" id="label_4"></div><div id="cid_4" 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_4" /><label id="label_input_4" for="input_4">I would like to receive news and updates by email</label></div> </div></li><li class="form-line" id="id_5"><div class="form-label-left" id="label_5"><label for="input_5"> Phone<span class="form-required">*</span> </label><label class="label-message" for="input_5"> </label></div><div id="cid_5" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox validate[required, Numeric]" type="tel" name="q5_phoneNumber[area]" id="input_5_area" autocomplete="tel-area-code" maxlength="5" size="3" />  <label class="form-sub-label" for="input_5_area" id="sublabel_area">Area Code</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required, Numeric]" type="tel" name="q5_phoneNumber[phone]" id="input_5_phone" autocomplete="tel-local" size="8" />  <label class="form-sub-label" for="input_5_phone" id="sublabel_phone">Phone Number</label></span></div> </div></li><li class="form-line" id="id_13"><div class="form-label-left" id="label_13"><label for="input_13"> No. of Adults </label><label class="label-message" for="input_13"> $100 per adult</label></div><div id="cid_13" class="form-input"> <input type="number" class="form-number-input  form-textbox" id="input_13" name="q13_number" style="width:60px" size="5" value="" data-type="input-number" autocomplete="nope" min="0" data-numbermin="0" /> </div></li><li class="form-line" id="id_14"><div class="form-label-left" id="label_14"><label for="input_14"> No. of Children </label><label class="label-message" for="input_14"> $50 per child (2-12)</label></div><div id="cid_14" class="form-input"> <input type="number" class="form-number-input  form-textbox" id="input_14" name="q14_number14" style="width:60px" size="5" value="" data-type="input-number" autocomplete="nope" min="0" data-numbermin="0" /> </div></li><li class="form-line" id="id_18"><div class="form-label-left" id="label_18"><label for="input_18"> No. of CYP Attendees </label><label class="label-message" for="input_18"> $50 per attendee</label></div><div id="cid_18" class="form-input"> <input type="number" class="form-number-input  form-textbox" id="input_18" name="q18_number18" style="width:60px" size="5" value="" data-type="input-number" autocomplete="nope" min="0" data-numbermin="0" /> </div></li><li class="form-line" id="id_15"><div class="form-label-left" id="label_15"><label for="input_15"> No. of VIP Seats </label><label class="label-message" for="input_15"> $360 per VIP seat</label></div><div id="cid_15" class="form-input"> <input type="number" class="form-number-input  form-textbox" id="input_15" name="q15_number15" style="width:60px" size="5" value="" data-type="input-number" autocomplete="nope" min="0" data-numbermin="0" /> </div></li><li class="form-line" id="id_11"><div class="form-label-left" id="label_11"><label for="input_11"> VIP Table </label><label class="label-message" for="input_11"> </label></div><div id="cid_11" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_11_0" name="q11_input11[]" value="I would like to be a Shabbos Ambassador with a VIP table of 10! $3,600" /><label id="label_input_11_0" for="input_11_0"><span>I would like to be a Shabbos Ambassador with a VIP table of 10! $3,600</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_19"><div class="form-label-left" id="label_19"><label for="input_19"> Names of Guests<span class="form-required">*</span> </label><label class="label-message" for="input_19"> </label></div><div id="cid_19" class="form-input"> <textarea id="input_19" class="form-textarea validate[required]" name="q19_input19" cols="40" rows="3"></textarea> </div></li><li class="form-line" id="id_6"><div id="cid_6" class="form-input-wide"> <div id="text_6" class="form-html"><p>Please note: This event on Friday will be hosted at The Colony Hotel ballroom and east garden venue spaces. If you choose to stay for the entire Shabbos please call the hotel directly at 561-655-5430 to book a room; please request the Shabbat 24|6 group rate. Please call The Chabad House office at 561-659-3884 for any questions. We would love to hear from you!</p>
</div> </div></li><li class="form-line" id="id_7"><div class="form-label-left" id="label_7"><label for="input_7"> Sponsorship Opportunities  </label><label class="label-message" for="input_7"> Sponsorships of $3,600 and up includes a VIP table of 10</label></div><div id="cid_7" class="form-input"> <div class="form-multiple-column" data-columns="2"><span class="form-radio-item"><input type="radio" class="form-radio" id="input_7_0" name="q7_input7" value="1000" /><label for="input_7_0"><span>$1000</span></label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio" id="input_7_1" name="q7_input7" value="3600" /><label for="input_7_1"><span>$3600</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_7_2" name="q7_input7" value="10000" /><label for="input_7_2"><span>$10000</span></label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio" id="input_7_3" name="q7_input7" value="18000" /><label for="input_7_3"><span>$18000</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio-other form-radio" name="q7_input7" id="other_7" value="" /><span><input type="number" min="1" class="form-radio-other-input form-textbox" onkeypress="validateNumber(event)" name="q7_input7[other]" data-otherhint="Other" size="15" id="input_7" disabled="disabled" /></span><br /></span></div> </div></li><li class="form-line" id="id_16"><div class="form-label-left" id="label_16"><label for="input_16"> Membership </label><label class="label-message" for="input_16"> </label></div><div id="cid_16" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_16_0" name="q16_input16[]" value="Please consider my contribution as my membership" /><label id="label_input_16_0" for="input_16_0"><span>Please consider my contribution as my membership</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_12"><div class="form-label-left" id="label_12"><label for="input_12"> Total </label></div><div id="cid_12" class="form-input"> <div id="total_amount">$0.00 </div> </div></li><li class="form-line" id="id_8"><div class="form-label-left" id="label_8"><label for="input_8"> Payment </label><label class="label-message" for="input_8"> </label></div><div id="cid_8" 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_8_creditCard" name="q8_payment[payment_method]" value="creditCard" onclick="BuildSource.creditCard(this)" /><label for="input_8_creditCard">Credit Card</label> </span><span class="form-radio-item"><input class="paymentMethod form-radio validate[paymentMethod] form-radio" type="radio" id="input_8_paypal" name="q8_payment[payment_method]" value="paypal" onclick="BuildSource.paypal(this)" /><label for="input_8_paypal">Paypal</label> </span><span class="form-radio-item"><input class="paymentMethod form-radio validate[paymentMethod] form-radio" type="radio" id="input_8_other" name="q8_payment[payment_method]" value="other" onclick="BuildSource.other(this)" /><label for="input_8_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="q8_payment[cc_type]" id="input_8_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="q8_payment[cc_number]" id="input_8_cc_number" autocomplete="cc-number" size="20" />  <label class="form-sub-label" for="input_8_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="q8_payment[cc_ccv]" id="input_8_cc_ccv" autocomplete="cc-csc" size="6" />  <label class="form-sub-label" for="input_8_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="q8_payment[cc_nameOnCard]" id="input_8_cc_nameOnCard" autocomplete="cc-name" size="33" />  <label class="form-sub-label" for="input_8_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="q8_payment[cc_exp_month]" id="input_8_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_8_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="q8_payment[cc_exp_year]" id="input_8_cc_exp_year" autocomplete="cc-exp-year"><option></option><option value="2024">2024</option><option value="2025">2025</option><option value="2026">2026</option><option value="2027">2027</option><option value="2028">2028</option><option value="2029">2029</option><option value="2030">2030</option><option value="2031">2031</option><option value="2032">2032</option><option value="2033">2033</option></select>  <label class="form-sub-label" for="input_8_cc_exp_year" id="sublabel_cc_exp_year">Expiration Year</label></span></td></tr></tbody></table></td></tr><tr class="paypal hide"><td colspan="2">Paypal has been selected. Payment will take place on the next page.</td></tr><tr class="other hide"><td colspan="2">Checks can be made payable to The Chabad House and mailed to 361 S. County Rd. Palm Beach, FL 33480.</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="q8_payment[addr_line1]" id="input_8_addr_line1" autocomplete="billing address-line1" />  <label class="form-sub-label" for="input_8_addr_line1" id="sublabel_8_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="q8_payment[city]" id="input_8_city" autocomplete="billing address-level2" />  <label class="form-sub-label" for="input_8_city" id="sublabel_8_city">City</label></span></td><td><span class="form-sub-label-container"><input class="form-textbox form-address-state" type="text" name="q8_payment[state]" id="input_8_state" autocomplete="billing address-level1" />  <label class="form-sub-label" for="input_8_state" id="sublabel_8_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="q8_payment[postal]" id="input_8_postal" size="10" autocomplete="billing postal-code" />  <label class="form-sub-label" for="input_8_postal" id="sublabel_8_postal">Postal / Zip Code</label></span></td><td><span class="form-sub-label-container"><select class="form-dropdown form-address-country" name="q8_payment[country]" id="input_8_country" autocomplete="billing country-name"><option value="" selected="selected">Please Select</option><option selected="selected" 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 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="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 value="South Africa">South Africa</option><option value="South Ossetia">South Ossetia</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">Svalbard</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 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