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            background: url('https://valleychabad.org/media/images/1322/DJQl13220255.png');
            background-size: 100% 100%;
            background-repeat: no-repeat;
            background-color: #275992;
        }
        .cco_templateless_page .chabad_header, .chabad_header {
            background-blend-mode: normal !important;
        }
        .chabad_header div {
            visibility: hidden;
        }
        div.chabad_left_column {
            background: transparent;
        }
        .large_banner, .sPromo-wrap {
            border: 2px solid #275992;
        }
        .large_banner .bannerCta button {
            background: #275992;
            border: 3px solid #275992;
        }
        .large_banner .big {
            color: #275992;
            font-weight: bold;
        }
        .large_banner .wrapper-message {
            margin-block: 1.5em !important;
        }
        .sPromo-wrap .caption {
            color: black !important;
        }
        .sPromo-wrap img {
            border: 0px !important;
        }
        .custom_message .message {
            color: black !important;
        }
        .custom_message .title {
            color: #275992 !important;
        }
        .custom_message .read-more_link a {
            color: #275992 !important;
            border: 3px solid #275992 !important;
        }
        .custom_message .read-more_link a:hover {
            background: #275992 !important;
            color: white !important;
        }
        .prepResource-title, .co_calendar_head div, .features_title {
            font-size: 25pt !important;
            color: #275992 !important;
        }
        .prep-title, .feature_caption a {
            color: #275992 !important;
        }
        .zmanim .zman-1, .zmanim .zman-2 {
            border-radius: 10px !important;
            background: #275992 !important;
            margin: 5px 0px !important;
        }
        #co_calendar div.co_calendar_body .item.item.first,
        #co_calendar div.co_calendar_body .item:nth-child(3),
        #co_calendar div.co_calendar_body .item:nth-child(6),
        #co_calendar div.co_calendar_body .item:nth-child(8) {
            background: #275992;
        }
        #co_calendar div.co_calendar_body .item:nth-child(2),
        #co_calendar div.co_calendar_body .item:nth-child(4),
        #co_calendar div.co_calendar_body .item:nth-child(5),
        #co_calendar div.co_calendar_body .item:nth-child(7) {
            background: #e4c1aa;
        }
        .footer, .footer a {
            background: #275992;
            color: white !important;
        }
        .cco_templateless_template a,
        .div#chabad_head .chabad_navigator_bar,
        #menu .item,
        #navigation,
        #menu a {
            background: #275992 !important;
        }
        #menu a {
            color: white !important;
            border: 0px !important;
        }
        .selected a {
            text-decoration: underline !important;
        }
        #menu .item {
            color: transparent !important;
        }
        .titleIcon img {
            width: 125px !important;
            display: none !important;
        }
        .co_calendar_head:before,
        .pesach-resources .titleIcon {
            display: none !important;
        }
        div#chabad_body_content {
            background: transparent !important;
        }
        .co_calendar_text {
            background-color: transparent !important;
        }

        @media all and (max-width: 500px) {
            .chabad_header {
                height: 200px !important;
            }
            .headerTitle {
                display: none;
            }
            .body.section_root .bh {
                right: 25px !important;
                color: white !important;
            }
        }
    `;
    document.head.appendChild(style);
}
</script><script>
if (document.location.href.indexOf('6443141') > -1) {
    const style = document.createElement('style');
    style.innerHTML = `
        .cco_templateless_page #chabad_main_content {
            background: url('https://villagechabad.org/media/images/1277/uELu12776014.png') !important;
            background-size: cover !important;
            background-position: bottom !important;
        }
        .footer, .footer a {
            background-color: #275992 !important;
            color: white !important;
        }
        .chabad_header {
            background: url('https://valleychabad.org/media/images/1322/DJQl13220255.png');
            background-size: 100% 100%;
            background-repeat: no-repeat;
            background-color: #275992;
        }
        .cco_templateless_page .chabad_header, .chabad_header {
            background-blend-mode: normal !important;
        }
        .chabad_header div {
            visibility: hidden;
        }
        div.chabad_left_column {
            background: transparent;
        }
        .large_banner, .sPromo-wrap {
            border: 2px solid #275992;
        }
        .large_banner .bannerCta button {
            background: #275992;
            border: 3px solid #275992;
        }
        .large_banner .big {
            color: #275992;
            font-weight: bold;
        }
        .large_banner .wrapper-message {
            margin-block: 1.5em !important;
        }
        .sPromo-wrap .caption {
            color: black !important;
        }
        .sPromo-wrap img {
            border: 0px !important;
        }
        .custom_message .message {
            color: black !important;
        }
        .custom_message .title {
            color: #275992 !important;
        }
        .custom_message .read-more_link a {
            color: #275992 !important;
            border: 3px solid #275992 !important;
        }
        .custom_message .read-more_link a:hover {
            background: #275992 !important;
            color: white !important;
        }
        .prepResource-title, .co_calendar_head div, .features_title {
            font-size: 25pt !important;
            color: #275992 !important;
        }
        .prep-title, .feature_caption a {
            color: #275992 !important;
        }
        .zmanim .zman-1, .zmanim .zman-2 {
            border-radius: 10px !important;
            background: #275992 !important;
            margin: 5px 0px !important;
        }
        #co_calendar div.co_calendar_body .item.item.first,
        #co_calendar div.co_calendar_body .item:nth-child(3),
        #co_calendar div.co_calendar_body .item:nth-child(6),
        #co_calendar div.co_calendar_body .item:nth-child(8) {
            background: #275992;
        }
        #co_calendar div.co_calendar_body .item:nth-child(2),
        #co_calendar div.co_calendar_body .item:nth-child(4),
        #co_calendar div.co_calendar_body .item:nth-child(5),
        #co_calendar div.co_calendar_body .item:nth-child(7) {
            background: #e4c1aa;
        }
        .footer, .footer a {
            background: #275992;
            color: white !important;
        }
        .cco_templateless_template a,
        .div#chabad_head .chabad_navigator_bar,
        #menu .item,
        #navigation,
        #menu a {
            background: #275992 !important;
        }
        #menu a {
            color: white !important;
            border: 0px !important;
        }
        .selected a {
            text-decoration: underline !important;
        }
        #menu .item {
            color: transparent !important;
        }
        .titleIcon img {
            width: 125px !important;
            display: none !important;
        }
        .co_calendar_head:before,
        .pesach-resources .titleIcon {
            display: none !important;
        }
        div#chabad_body_content {
            background: transparent !important;
        }
        .co_calendar_text {
            background-color: transparent !important;
        }

        @media all and (max-width: 500px) {
            .chabad_header {
                height: 200px !important;
            }
            .headerTitle {
                display: none;
            }
            .body.section_root .bh {
                right: 25px !important;
                color: white !important;
            }
        }
    `;
    document.head.appendChild(style);
}
</script><script>
if (document.location.href.indexOf('4874299') > -1) {
 
    // Add CSS styles
    var style = document.createElement('style');
    style.type = 'text/css';
    style.innerHTML = `
        #formContainer .form-all {
            background: #ffffff;
            border-radius: 12px;
            box-shadow: 0 4px 20px rgba(0, 0, 0, 0.1);
            max-width: 600px;
            margin: 40px auto;
            padding: 40px;
            font-family: -apple-system, BlinkMacSystemFont, "Segoe UI", Roboto, sans-serif;
        }
.master-content-wrapper.g960 {
    display: none !important;
}
        .co_body {
            background-image: url('https://valleychabad.org/media/images/1330/GZLi13303392.png') !important;
            background-repeat: no-repeat !important;
            background-size: cover !important;
            background-position: center !important;
        }
.co_body .content .form-all .form-image {
    height: auto;
    padding-right: 30px; !important
}

        .body_wrapper.co_body {
            margin-left: 0 !important;
            margin-right: 0 !important;
            width: 100% !important;
        }

        #formContainer .form-section {
            list-style: none;
            padding: 0;
            margin: 0;
        }
        
        #formContainer .form-line {
            margin-bottom: 24px;
            padding: 0;
        }
        
        #formContainer .form-label-left {
            width: 100% !important;
            float: none !important;
            margin-bottom: 8px;
        }
        
        #formContainer .form-label-left label {
            font-weight: 600;
            color: #2c3e50;
            font-size: 14px;
            display: block;
        }
        
        #formContainer .form-required {
            color: #e74c3c;
            margin-left: 4px;
        }
        
        #formContainer .form-input {
            width: 100%;
        }
        
        #formContainer .form-textbox,
        #formContainer .form-textarea,
        #formContainer .form-dropdown,
        #formContainer select {
                width: 100% !important;
                padding: 20px 16px;
                border: 2px solid #e1e8ed;
                border-radius: 8px;
                font-size: 20px;
                transition: all 0.3s ease;
                background: #ffffff;
                box-sizing: border-box;
                line-height: 20px;
                color: #8f8989;
                font-weight: bold;
        }
        
        #formContainer .form-textbox:focus,
        #formContainer .form-textarea:focus,
        #formContainer .form-dropdown:focus,
        #formContainer select:focus {
            outline: none;
            border-color: #3498db;
            box-shadow: 0 0 0 3px rgba(52, 152, 219, 0.1);
        }
        
        /* Amount selection styling */
        #formContainer #id_3 .form-multiple-column {
            display: grid;
            grid-template-columns: repeat(auto-fit, minmax(120px, 1fr));
            gap: 12px;
            margin-top: 8px;
        }
        
        #formContainer .form-radio-item {
            margin: 0 !important;
            width: 100%;
        }
        
        #formContainer .form-radio-item label {
            display: block;
            padding: 16px 20px;
            background: #b9babc;
            border: 2px solid #e1e8ed;
            border-radius: 8px;
            text-align: center;
            font-weight: 600;
            font-size: 16px;
            color: #2c3e50;
            cursor: pointer;
            transition: all 0.3s ease;
            margin: 0;
            width: 100%;
        }
        
        #formContainer .form-radio-item input[type="radio"] {
            display: none;
        }
        
        #formContainer .form-radio-item input[type="radio"]:checked + label {
            background: #3498db;
            color: white;
            border-color: #3498db;
            transform: translateY(-2px);
        }
        
        #formContainer .form-radio-item label:hover {
            background: #e8f4fd;
            border-color: #3498db;
        }
        
        #formContainer .form-radio-item input[type="radio"]:checked + label:hover {
            background: #2980b9;
        }
        
        /* Other amount field */
        #formContainer .form-radio-other-input {
            width: 100% !important;
            margin-top: 8px;
            padding: 12px 16px;
            border: 2px solid #e1e8ed;
            border-radius: 8px;
        }
        
        /* Address fields */
        #formContainer .form-address-table {
            width: 100%;
        }
        
        #formContainer .form-address-table td {
            padding: 4px;
            vertical-align: top;
        }
        
        #formContainer .form-sub-label-container {
            position: relative;
            display: block;
            margin-bottom: 16px;
        }
        
        #formContainer .form-sub-label {
            font-size: 12px;
            color: #7f8c8d;
            margin-top: 4px;
            display: block;
        }
        
        /* Phone number fields */
        #formContainer #cid_7 .form-sub-label-container {
            display: inline-block;
            width: 48%;
            margin-right: 4%;
            vertical-align: top;
        }
        
        #formContainer #cid_7 .form-sub-label-container:last-child {
            margin-right: 0;
        }
        
        /* Checkbox styling */
        #formContainer .form-checkbox-item {
            margin: 16px 0;
        }
        
        #formContainer .form-checkbox {
            width: 18px;
            height: 18px;
            margin-right: 12px;
            vertical-align: middle;
        }
        
        #formContainer .form-checkbox + label {
            vertical-align: middle;
            font-size: 14px;
            line-height: 1.5;
        }
        
        /* Total amount styling */
        #formContainer #total_amount {
            font-size: 24px;
            font-weight: 700;
            color: #3498db;
            text-align: center;
            padding: 20px;
            background: #f8f9fa;
            border-radius: 8px;
            margin-bottom: 16px;
        border: 2px solid #3498db;
        }
        
        /* Payment method styling */
        #formContainer .form-payment-methods .form-radio-item {
            display: inline-block;
            margin-right: 20px;
        }
        
        #formContainer .form-payment-methods .form-radio-item label {
            padding: 12px 24px;
            background: #f8f9fa;
            border: 2px solid #e1e8ed;
            border-radius: 8px;
            display: inline-block;
        }
        
        #formContainer .form-payment-methods input[type="radio"]:checked + label {
            background: #3498db;
            color: white;
            border-color: #3498db;
        }
        
        /* Credit card icons */
        #formContainer .cc-icons {
            display: flex;
            gap: 8px;
            margin: 8px 0;
        }
        
        #formContainer .cc-icon {
            width: 32px;
            height: 20px;
            background-size: contain;
            background-repeat: no-repeat;
        }
        
        /* Submit button */
        #formContainer .form-submit-button {
            width: 100%;
            padding: 16px 32px;
            background: #27ae60;
            color: white;
            border: none;
            border-radius: 8px;
            font-size: 18px;
            font-weight: 600;
            cursor: pointer;
            transition: all 0.3s ease;
            text-transform: uppercase;
            letter-spacing: 0.5px;
        }
        
        #formContainer .form-submit-button:hover {
            background: #229954;
            transform: translateY(-2px);
            box-shadow: 0 6px 20px rgba(39, 174, 96, 0.3);
        }
        
        #formContainer .form-buttons-wrapper {
            text-align: center;
            text-indent: 0 !important;
        }
        
        /* Responsive design */
        @media (max-width: 768px) {
            #formContainer .form-all {
                margin: 20px;
                padding: 24px;
            }
            
            #formContainer #id_3 .form-multiple-column {
                grid-template-columns: repeat(2, 1fr);
            }
            
            #formContainer .form-address-table td {
                display: block;
                width: 100% !important;
                padding: 2px 0;
            }
            
            #formContainer #cid_7 .form-sub-label-container {
                width: 100%;
                margin-right: 0;
                margin-bottom: 16px;
            }
            
            #formContainer .form-payment-methods .form-radio-item {
                display: block;
                margin-right: 0;
                margin-bottom: 12px;
            }
        }
        
        @media (max-width: 480px) {
            #formContainer #id_3 .form-multiple-column {
                grid-template-columns: 1fr;
            }
        }
        
        /* Hide clearfix elements */
        #formContainer .clearfix {
            display: none;
        }

        .co_body .content .form-all .form-input {
            display: block;
        }
    `;

    document.head.appendChild(style);

    // Add some JavaScript enhancements
    setTimeout(function() {
        // Auto-calculate total when amount is selected
        var radioButtons = document.querySelectorAll('#formContainer input[name="q3_input3"]');
        var totalDisplay = document.querySelector('#formContainer #total_amount');
        var otherInput = document.querySelector('#formContainer #input_3');

        radioButtons.forEach(function(radio) {
            radio.addEventListener('change', function() {
                var amount = this.value;
                if (amount && totalDisplay) {
                    totalDisplay.textContent = '$' + amount + '.00';
                }

                // Enable/disable other input
                if (this.id === 'other_3') {
                    otherInput.disabled = false;
                    otherInput.focus();
                } else {
                    otherInput.disabled = true;
                }
            });
        });

        // Handle other amount input
        if (otherInput) {
            otherInput.addEventListener('input', function() {
                if (this.value && totalDisplay) {
                    totalDisplay.textContent = '$' + this.value + '.00';
                }
            });
        }

        // Show/hide credit card fields based on payment method
        var paymentMethods = document.querySelectorAll('#formContainer input[name="q12_payment[payment_method]"]');
        var creditCardRows = document.querySelectorAll('#formContainer .credit_card');
        var paypalRows = document.querySelectorAll('#formContainer .paypal');

        paymentMethods.forEach(function(method) {
            method.addEventListener('change', function() {
                if (this.value === 'creditCard') {
                    creditCardRows.forEach(function(row) {
                        row.classList.remove('hide');
                    });
                    paypalRows.forEach(function(row) {
                        row.classList.add('hide');
                    });
                } else if (this.value === 'paypal') {
                    creditCardRows.forEach(function(row) {
                        row.classList.add('hide');
                    });
                    paypalRows.forEach(function(row) {
                        row.classList.remove('hide');
                    });
                }
            });
        });
    }, 500);
}
</script><script>
function applyCustomStyles(pageId, css) {
    if (document.location.href.indexOf(pageId) > -1) {
        const style = document.createElement('style');
        style.innerHTML = css;
        document.head.appendChild(style);
    }
}
const baseStyles = `
/* === GENERAL LAYOUT === */
.cco_templateless_page #chabad_main_content {
  background-size: cover !important;
  background-position: bottom !important;
  background-color: #FFFFFF;
}
.chabad_header {
  background: url('https://valleychabad.org/media/images/1328/CsqH13286279.png') no-repeat center center !important;
background-size: cover !important;;  
  background-color: #1695A4 !important;
}
.cco_templateless_page .chabad_header, .chabad_header{
background-blend-mode: normal !important;
background-color: #1695A4 !important;
}

.chabad_header div {
  visibility: hidden;
}
div.chabad_left_column {
  background: transparent !important;
}

/* === LARGE BANNER === */
.large_banner {
  border: 0px solid #1695A4 !important;
}
.large_banner .bannerCta button {
  background: #FFA800 !important;
  border: 3px solid #FFA800 !important;
  color: white !important;
  font-weight: bold;
  padding: 10px 25px;
  border-radius: 5px;
  font-size: 16px;
}
.large_banner .bannerCta button:hover {
  background: white !important;
  color: #1695A4 !important;
}
.large_banner .big {
  color: #000000 !important;
  font-weight: bold;
}
.large_banner .wrapper-message {
  margin-block: 1.5em !important;
}

/* === CUSTOM PROMOS === */
.sPromo-wrap img {
  border: 0px !important;
}
.sPromo-wrap .caption {
  color: black !important;
}

/* === CUSTOM MESSAGES === */
.custom_message .title,
.custom_message .read-more_link a,
.prepResource-title,
.co_calendar_head div,
.features_title,
.prep-title,
.feature_caption a {
  color: #1695A4 !important;
}
.custom_message .read-more_link a {
  border: 3px solid #1695A4 !important;
}
.custom_message .read-more_link a:hover {
  background: #1695A4 !important;
  color: white !important;
}
.custom_message .message {
  color: black !important;
}

/* === SPECIAL SECTIONS === */
#holiday_appeal {
  background-color: #D1EDFB !important;
  padding: 1.5em;
  border-radius: 10px;
}

/* ✅ Restore “Learn More” Section Background */
#local_events,
.latest_features,
#latest_features,
.features #latest_features,
#latest_features .feature-inner {
  background: url('https://valleychabad.org/media/images/1328/kzWB13286287.png') no-repeat center center !important;
  background-size: cover !important;
  padding: 2em;
  border-radius: 20px;
}
#local_events h2,
.latest_features h2,
#latest_features h2 {
  color: #1695A4 !important;
}
#local_events .read-more_link a,
.latest_features .read-more_link a,
#latest_features .read-more_link a {
  background: #FFA800 !important;
  padding: 10px 20px;
  border-radius: 5px;
  display: inline-block;
  text-decoration: none;
  font-weight: bold;
  color: white !important;
}
#local_events .read-more_link a:hover,
.latest_features .read-more_link a:hover,
#latest_features .read-more_link a:hover {
  background: #d18f00 !important;
}

/* === CHILD PAGE TITLE COLOR === */
.prepResource-title,
.co_calendar_head div,
.features_title,
h1, h2, .feature_caption a {
  color: #FFA800 !important;
}

/* === CALENDAR / ZMANIM === */
.zmanim .zman-1, .zmanim .zman-2 {
  border-radius: 10px !important;
  background: #1695A4 !important;
  margin: 5px 0px !important;
}
#co_calendar,
div.co_calendar_body {
  background: url('https://valleychabad.org/media/images/1328/kzWB13286287.png') no-repeat center center !important;
  background-size: cover !important;
  padding: 2em;
  border-radius: 20px;
}
#co_calendar div.co_calendar_body .item.item.first,
#co_calendar div.co_calendar_body .item:nth-child(3),
#co_calendar div.co_calendar_body .item:nth-child(6),
#co_calendar div.co_calendar_body .item:nth-child(8) {
  background: #1695A4;
}
#co_calendar div.co_calendar_body .item:nth-child(2),
#co_calendar div.co_calendar_body .item:nth-child(4),
#co_calendar div.co_calendar_body .item:nth-child(5),
#co_calendar div.co_calendar_body .item:nth-child(7) {
  background: #1695A4;
}
.co_calendar_text {
  background-color: transparent !important;
}

/* === FOOTER & NAVIGATION === */
.footer, .footer a {
  background: #1695A4 !important;
  color: white !important;
}
#menu, #menu a, #navigation, .div#chabad_head .chabad_navigator_bar, #menu .item {
  background: #1695A4 !important;
}
.cco_templateless_template a, .div#chabad_head .chabad_navigator_bar, #menu .item, #navigation, #menu a{
background:#1695A4 !important;
}
#menu a{
color:white !important;
border:0px !important;
}
.selected a{
text-decoration:underline !important;
}
#menu .item{
color:transparent !important;
}
.titleIcon img{
width:125px !important;
}


/* === CLEANUP === */
img[src*="High-Holidays_shofer.png"],
img[src*="High-Holidays_book.png"],
img[src*="High-Holidays_apple.png"],
.co_calendar_head:before,
.pesach-resources .titleIcon {
  display: none !important;
}
div#chabad_body_content {
  background: transparent !important;
}

/* === RESPONSIVE === */
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			<h1 class="article-header__title js-article-title js-page-title">Yahrtzeit Observances</h1>
		
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<form class="userform-form" action="" method="post" name="form_6062100" id="6062100" accept-charset="utf-8"><input type="hidden" name="formID" value="6062100" /><div class="form-all dir_ltr" dir="ltr"><ul class="form-section"><li class="form-line" id="id_1"><div id="cid_1" class="form-input-wide"> <div id="text_1" class="form-html"><p><span style="font-size:16px;"><strong>Kiddush</strong></span></p>

<p>A Kiddush joins the community for blessings and inspiration and bring merit to you and your departed relative. See the kiddush form <a href="https://www.valleychabad.org/Article.asp?AID=3824911">here</a>.</p>
</div> </div></li><li class="form-line" id="id_3"><div id="cid_3" class="form-input-wide"> <div id="text_3" class="form-html"><p><span style="font-size:16px;"><strong>Book</strong></span></p>

<p>A book for prayers and/or learning that you sponsor will add merit for your relative. Books are an important way to invest in your community.</p>
</div> </div></li><li class="form-line" id="id_4"><div class="form-label-left" id="label_4"><label for="input_4"> Book </label><label class="label-message" for="input_4"> </label></div><div id="cid_4" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_4_0" name="q4_input4[]" value="I would like to sponsor Torah/Bibles to Valley Chabad ($54/each)" /><label id="label_input_4_0" for="input_4_0"><span>I would like to sponsor Torah/Bibles to Valley Chabad ($54/each)</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_4_1" name="q4_input4[]" value="I would like to sponsor Library books to Valley Chabad ($36/each)" /><label id="label_input_4_1" for="input_4_1"><span>I would like to sponsor Library books to Valley Chabad ($36/each)</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_5"><div id="cid_5" class="form-input-wide"> <div id="text_5" class="form-html"><p><span style="font-size:16px;"><strong>Plaque</strong></span></p>

<p>The Valley Chabad Memorial Wall is a testament to the giants on who’s shoulders our community stands. Each year during the month of Yahrtzeit the light near your relatives name will be turned on. Four times a year during Yizkor all names on the Memorial board have their lights turned on.</p>
</div> </div></li><li class="form-line" id="id_6"><div class="form-label-left" id="label_6"><label for="input_6"> Plaque </label><label class="label-message" for="input_6"> </label></div><div id="cid_6" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_6_0" name="q6_input6[]" value="I would like a memorial plaque for my relative on the Valley Chabad Memorial Wall ($500)" /><label id="label_input_6_0" for="input_6_0"><span>I would like a memorial plaque for my relative on the Valley Chabad Memorial Wall ($500)</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_7"><div id="cid_7" class="form-input-wide"> <div id="text_7" class="form-html"><p><span style="font-size:16px;"><strong>Learning </strong></span></p>

<p>Sponsoring a Torah class, a day of Hebrew School or a scholarship for a child in need for a year of Hebrew School is a special way to bring merit to the departed and your family.</p>
</div> </div></li><li class="form-line" id="id_8"><div class="form-label-left" id="label_8"><label for="input_8"> Learning </label><label class="label-message" for="input_8"> </label></div><div id="cid_8" class="form-input"> <div class="form-single-column"><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_8_0" name="q8_input8[]" value="Hebrew School for one day $540" /><label id="label_input_8_0" for="input_8_0"><span>Hebrew School for one day $540</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_8_1" name="q8_input8[]" value="A year of Hebrew School for a child $1,300" /><label id="label_input_8_1" for="input_8_1"><span>A year of Hebrew School for a child $1,300</span></label></span><span class="clearfix"></span><span class="form-checkbox-item clear-left"><input type="checkbox" class="form-checkbox" id="input_8_2" name="q8_input8[]" value="A Torah Class $180" /><label id="label_input_8_2" for="input_8_2"><span>A Torah Class $180</span></label></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_9"><div class="form-label-left" id="label_9"><label for="input_9"> Donate </label><label class="label-message" for="input_9"> In addition to the dedications selected I would like to partner with Valley Chabad in it’s vital community work.</label></div><div id="cid_9" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_9_0" name="q9_input9" value="$3,600" /><label id="label_input_9_0" for="input_9_0"><span>$3,600</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_9_1" name="q9_input9" value="$1,800" /><label id="label_input_9_1" for="input_9_1"><span>$1,800</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_9_2" name="q9_input9" value="$1,000" /><label id="label_input_9_2" for="input_9_2"><span>$1,000</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_9_3" name="q9_input9" value="$540" /><label id="label_input_9_3" for="input_9_3"><span>$540</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_9_4" name="q9_input9" value="$360" /><label id="label_input_9_4" for="input_9_4"><span>$360</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_9_5" name="q9_input9" value="$180" /><label id="label_input_9_5" for="input_9_5"><span>$180</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_9_6" name="q9_input9" value="$100" /><label id="label_input_9_6" for="input_9_6"><span>$100</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_9_7" name="q9_input9" value="$54" /><label id="label_input_9_7" for="input_9_7"><span>$54</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_9_8" name="q9_input9" value="$36" /><label id="label_input_9_8" for="input_9_8"><span>$36</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_9_9" name="q9_input9" value="$18" /><label id="label_input_9_9" for="input_9_9"><span>$18</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio-other form-radio validate[other]" name="q9_input9" id="other_9" value="" /><span><input type="text" form-radio="" class="form-radio-other-input form-textbox " name="q9_input9[other]" data-otherhint="Other" size="15" id="input_9" disabled="disabled" /></span><br /></span></div> </div></li><li id="cid_10" class="form-input-wide"> <div class="form-header-group"><h2 id="header_10" class="form-header">Contact Information</h2></div> </li><li class="form-line" id="id_11"><div class="form-label-left" id="label_11"><label for="input_11"> Your Full Name<span class="form-required">*</span> </label><label class="label-message" for="input_11"> </label></div><div id="cid_11" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q11_fullName[first]" id="first_11" autocomplete="given-name" />  <label class="form-sub-label" for="first_11" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q11_fullName[last]" id="last_11" autocomplete="family-name" />  <label class="form-sub-label" for="last_11" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_12"><div class="form-label-left" id="label_12"><label for="input_12"> E-mail<span class="form-required">*</span> </label><label class="label-message" for="input_12"> </label></div><div id="cid_12" class="form-input"> <input type="email" class=" form-textbox validate[required, Email]" id="input_12" name="q12_email" size="30" value="" autocomplete="email" /> </div></li><li class="form-line" id="id_14"><div class="form-label-left" id="label_14"><label for="input_14"> Phone Number<span class="form-required">*</span> </label><label class="label-message" for="input_14"> </label></div><div id="cid_14" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input data-type="mask-number" class="mask-phone-number form-textbox validate[required]" type="tel" name="q14_phoneNumber[full]" id="input_14_full" autocomplete="tel" />  <label class="form-sub-label" for="input_14_full"><span> </span></label></span></div> </div></li><li class="form-line" id="id_15"><div class="form-label-left" id="label_15"><label for="input_15"> Payment </label><label class="label-message" for="input_15"> </label></div><div id="cid_15" 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_15_creditCard" name="q15_payment[payment_method]" value="creditCard" onclick="BuildSource.creditCard(this)" /><label for="input_15_creditCard">Credit Card</label> </span><span class="form-radio-item"><input class="paymentMethod form-radio validate[paymentMethod] form-radio" type="radio" id="input_15_paypal" name="q15_payment[payment_method]" value="paypal" onclick="BuildSource.paypal(this)" /><label for="input_15_paypal">Paypal</label> </span><span class="form-radio-item"><input class="paymentMethod form-radio validate[paymentMethod] form-radio" type="radio" id="input_15_other" name="q15_payment[payment_method]" value="other" onclick="BuildSource.other(this)" /><label for="input_15_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="q15_payment[cc_type]" id="input_15_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="q15_payment[cc_number]" id="input_15_cc_number" autocomplete="cc-number" size="20" />  <label class="form-sub-label" for="input_15_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="q15_payment[cc_ccv]" id="input_15_cc_ccv" autocomplete="cc-csc" size="6" />  <label class="form-sub-label" for="input_15_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="q15_payment[cc_nameOnCard]" id="input_15_cc_nameOnCard" autocomplete="cc-name" size="33" />  <label class="form-sub-label" for="input_15_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="q15_payment[cc_exp_month]" id="input_15_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_15_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="q15_payment[cc_exp_year]" id="input_15_cc_exp_year" autocomplete="cc-exp-year"><option></option><option value="2023">2023</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></select>  <label class="form-sub-label" for="input_15_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">Payable to Valley Chabad</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="q15_payment[addr_line1]" id="input_15_addr_line1" autocomplete="billing address-line1" />  <label class="form-sub-label" for="input_15_addr_line1" id="sublabel_15_addr_line1">Street Address</label></span></td></tr><tr class="billing_address hide"><td colspan="2"><span class="form-sub-label-container"><input class="form-textbox form-address-line no-validation" type="text" name="q15_payment[addr_line2]" id="input_15_addr_line2" size="46" autocomplete="billing address-line2" />  <label class="form-sub-label" for="input_15_addr_line2" id="sublabel_15_addr_line2">Street Address Line 2</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="q15_payment[city]" id="input_15_city" autocomplete="billing address-level2" />  <label class="form-sub-label" for="input_15_city" id="sublabel_15_city">City</label></span></td><td><span class="form-sub-label-container"><input class="form-textbox form-address-state" type="text" name="q15_payment[state]" id="input_15_state" autocomplete="billing address-level1" />  <label class="form-sub-label" for="input_15_state" id="sublabel_15_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="q15_payment[postal]" id="input_15_postal" size="10" autocomplete="billing postal-code" />  <label class="form-sub-label" for="input_15_postal" id="sublabel_15_postal">Postal / Zip Code</label></span></td><td><span class="form-sub-label-container"><select class="form-dropdown form-address-country" name="q15_payment[country]" id="input_15_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 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 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="Tristan da Cunha">Tristan da Cunha</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="Uruguay">Uruguay</option><option value="Uzbekistan">Uzbekistan</option><option value="Vanuatu">Vanuatu</option><option value="Vatican City">Vatican City</option><option value="Venezuela">Venezuela</option><option value="Vietnam">Vietnam</option><option value="British Virgin Islands">British Virgin Islands</option><option value="US Virgin Islands">US Virgin Islands</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><option value="other">Other</option></select>  <label class="form-sub-label" for="input_15_country" id="sublabel_15_country">Country</label></span></td></tr></tbody></table> </div></li><li id="cid_16" class="form-input-wide"> <div class="form-header-group"><h2 id="header_16" class="form-header">Honoree Information</h2></div> </li><li class="form-line" id="id_17"><div class="form-label-left" id="label_17"><label for="input_17"> English Name of Honoree </label><label class="label-message" for="input_17"> </label></div><div id="cid_17" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q17_fullName17[first]" id="first_17" autocomplete="given-name" />  <label class="form-sub-label" for="first_17" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="15" name="q17_fullName17[last]" id="last_17" autocomplete="family-name" />  <label class="form-sub-label" for="last_17" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_18"><div class="form-label-left" id="label_18"><label for="input_18"> Full Hebrew Name of Honoree </label><label class="label-message" for="input_18"> </label></div><div id="cid_18" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_18" name="q18_input18" size="20" value="" /> </div></li><li class="form-line" id="id_19"><div class="form-label-left" id="label_19"><label for="input_19"> Full Hebrew Name of Honoree </label><label class="label-message" for="input_19"> </label></div><div id="cid_19" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_19" name="q19_input19" size="20" value="" /> </div></li><li class="form-line" id="id_20"><div class="form-label-left" id="label_20"><label for="input_20"> English Date and Time of Passing </label><label class="label-message" for="input_20"> </label></div><div id="cid_20" class="form-input"> <div class="datetime-fields"><div class="dir_ltr date-fields"><span class="form-sub-label-container"><input class="form-textbox" id="month_20" name="q20_input20[month]" type="tel" size="2" maxlength="2" value="08" />  <label class="form-sub-label" for="month_20" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><input class="form-textbox" id="day_20" name="q20_input20[day]" type="tel" size="2" maxlength="2" value="25" />  <label class="form-sub-label" for="day_20" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><input class="form-textbox" id="year_20" name="q20_input20[year]" type="tel" size="4" maxlength="4" value="2023" />  <label class="form-sub-label" for="year_20" id="sublabel_year">Year</label></span><span class="form-sub-label-container"><img class="showAutoCalendar" alt="Pick a Date" id="input_20_pick" src="https://w2.chabad.org/images/sitecontrol/formbuilder/calendar.png" align="absmiddle" />  <label class="form-sub-label" for="input_20_pick"><span> </span></label></span></div><span class="dir_ltr inline_block time-fields" style="white-space: nowrap;"><span class="form-sub-label-container"><span id="at_20" class="form-control-static at-label">at</span>  <label class="form-sub-label" for="at_20"><span> </span></label></span><span class="form-sub-label-container"><select class="form-dropdown" id="hour_20" name="q20_input20[hour]"><option></option><option value="1">1</option><option value="2">2</option><option value="3">3</option><option value="4">4</option><option value="5">5</option><option value="6">6</option><option value="7">7</option><option value="8">8</option><option value="9">9</option><option value="10">10</option><option selected="selected" value="11">11</option><option value="12">12</option></select>  <label class="form-sub-label" for="hour_20" id="sublabel_hour">Hour</label></span><span class="form-sub-label-container"><select class="form-dropdown" id="min_20" 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