<!DOCTYPE HTML PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN" "http://www.w3.org/TR/html4/loose.dtd">

<html xmlns="http://www.w3.org/1999/xhtml" >
<head id="Head1">
<meta http-equiv="X-UA-Compatible" content="IE=edge" />
<meta http-equiv="Content-Type" content="text/html; charset=utf-8" />
<meta http-equiv="Content-Language" content="en" />

<meta property="og:image" content="https://w2.chabad.org/media/images/1166/sHOY11663551.png" itemprop="image" width="150" height="150" />
<meta property="og:image:width" content="150" />
<meta property="og:image:height" content="150" />
<meta name="keywords" content="Yizkor,Booklet" />
<meta name="title" content="Yizkor Booklet - Chabad Jewish Center Of Carroll County" />
<meta property="og:type" content="website" />
<meta name="scope-aids" content="2391190-2391198-5221241-4867875-4867926" />
<meta name="article-keywords" content="23366-2185-20429-8495-2170-2898-20962" />
<meta name="scope-aid" content="2391190" />
<meta name="scope-aid" content="2391198" />
<meta name="scope-aid" content="5221241" />
<meta name="scope-aid" content="4867875" />
<meta name="scope-aid" content="4867926" />
<meta name="article-keyword" content="23366" />
<meta name="article-keyword" content="2185" />
<meta name="article-keyword" content="20429" />
<meta name="article-keyword" content="8495" />
<meta name="article-keyword" content="2170" />
<meta name="article-keyword" content="2898" />
<meta name="article-keyword" content="20962" />
<meta property="og:url" content="https://www.jewishcarrollcounty.com/templates/articlecco_cdo/aid/4867926/jewish/Yizkor-Booklet.htm" />
<meta property="twitter:card" content="summary_large_image" />
<meta property="twitter:site" content="@chabad" />
<meta property="og:title" content="Yizkor Booklet - Chabad Jewish Center Of Carroll County" /><link rel="canonical" href="https://www.jewishcarrollcounty.com/templates/articlecco_cdo/aid/4867926/jewish/Yizkor-Booklet.htm" />
<link rel="icon" type="image/png" href="https://www.jewishcarrollcounty.com/media/images/1166/sHOY11663551.png" />
<link rel="Stylesheet" href="/css/fonts/font-awesome/font-awesome-5.css?v=98662BF4" id="kfont-awesome" type="text/css"/>
<link rel="Stylesheet" href="/css/DefaultGrid.css?v=44B79007" id="kgrid" type="text/css"/>
<link rel="Stylesheet" href="/css/Elements.css?v=E669C926" id="k6" type="text/css"/>
<link rel="Stylesheet" href="/css/vendor/ds/tokens/sites.css?v=D77AD1C0" id="ksites-ds-css" type="text/css"/>
<link rel="Stylesheet" href="/css/new/main.css?v=2B7F734E" id="k7" type="text/css"/>
<link rel="Stylesheet" href="https://w2.chabad.org/css/cco/minisites/global.css" id="k20962" type="text/css"/>
<link rel="Stylesheet" href="/css/old/global.css?v=F7C22456" id="k2898" type="text/css"/>
<link rel="Stylesheet" href="https://w2.chabad.org/images/Shluchim/minisites/themes/highholidays/high-holiday-minisite.css?v=1" id="k23366" type="text/css"/>
<link rel="Stylesheet" href="/css/cco/templates/forms/formCss2.css?v=9F45CAAB" id="kFormCss" type="text/css"/>
<link rel="Stylesheet" href="/css/cco/templates/forms/themes/nova.css?v=25554DFF" id="kNova" type="text/css"/>
<link rel="Stylesheet" href="/css/bootstrap/grid.css?v=B92FCAD8" id="kbootstrap4-grid" type="text/css"/>
<link rel="Stylesheet" href="/css/Library/reader-comments.css?v=5F31D0D8" id="kCommentsStylesheet" type="text/css"/>
<link rel="Stylesheet" href="/css/inline/BookInfo.css?v=14B88022" id="kBookInfoCss" type="text/css"/>

<script>$q=[];$j=function(f){$q.push(f);}</script>
	
 
	
	<style type="text/css">
		body{margin:0;}
	</style>
	
	



<script>
	window.dataLayer = window.dataLayer || [];
	dataLayer.push({"event":"datalayer-initialized","page":{"numberOfComments":0,"publicationDate":"2019-02-19","primaryArticleId":4867926,"title":"","author":"","authorId":0,"contentLevel1":"My Site","contentLevel2":"About Us","contentLevel3":"High Holidays","contentLevel4":"Yizkor Booklet","siteName":"Chabad Jewish Center Of Carroll County"},"time":{"upcomingHoliday":"Shavuot","daysToUpcomingHoliday":5,"hebrewDate":"5786-03-01"}});
		dataLayer.push({ 'articleHierarchy': '-2391190-2391198-5221241-4867875-4867926-', 'keywords': '-k20962-k2898-k2170-k8495-k20429-k2185-k23366-', 'k': '-2391190-2391198-5221241-4867875-4867926--k20962-k2898-k2170-k8495-k20429-k2185-k23366-' });
	
</script>
<script>

(function(c,h,a,b,a,d){c[a]=c[a]||[];c[a].push({'gtm.start':
new Date().getTime(),event:'gtm.js'});var f=h.getElementsByTagName(b)[0],
j=h.createElement(b);j.async=true;
j.src='https://w6.chabad.org/mitzvah-tank.js';f.parentNode.insertBefore(j,f);
})(window,document,0,'script','dataLayer');</script>

	<!-- Start of StatCounter Code -->
	<script type="text/javascript">
	var sc_project = 9483806;var sc_partition = 81;var sc_invisible = 1;var sc_remove_link=1;var sc_security = "6c676317";var sc_https = 1;
	</script>
	<script type="text/javascript" src="https://secure.statcounter.com/counter/counter_xhtml.js" defer async></script>
	<noscript><img src="//c82.statcounter.com/counter.php?sc_project=9483806&amp;java=0&amp;security=6c676317&amp;invisible=1" border="0" /> </noscript>
	<!-- End of StatCounter Code -->


<title>
	Yizkor Booklet - Chabad Jewish Center Of Carroll County
</title></head>
<body class="lang_en dir_ltr cco_body form secure cco_templateless_page section_branch">
	
	
		<div width="100%" class="cco_templateless_template" style="z-index:100 !important;display:block !important;left:0px !important;top:0px !important;height:30px!important;width:100% !important;line-height:30px !important; position:relative !important; margin-bottom:0 !important; padding:0;text-indent: 25px;" align="Left"><a href="//www.JewishCarrollCounty.com" style="display:block!important;font-size:14px !important;">&laquo; Back to&nbsp;Chabad Jewish Center Of Carroll County</a></div>
	
	<div class="cco_templatelates_content">
		
	<div class="co_content_container clearfix local_content" id="co_content_container">
		<div class="clearfix">
			<!-- BEGIN HEADER -->
<div id="chabad_body_page">
<div id="chabad_main_content">
<div id="chabad_head">


<div class="chabad_header">
<div class="headerTitle">
<a href="/4867875" style="text-decoration:none">

HIGH HOLIDAYS

</a>
</div>
<div class="centerName">

At
Chabad of Carroll County

</div>
<div class="holidayDates">



<div class="widget-1 holiday_date custom v260 feed">
<div class="wrapper">

<div class="widget_header">
<h5>Holiday Date</h5>    
</div>
<div class="widget_content">
September 11 - 21, 2026</div></div>
</div>


</div>
</div>


<div id="navigation" class="chabad_navigator_bar">
<div class="chabad_menu_content">
<ul id="menu" class="navi">
<li class="item parent">
<a href="/article.asp?aid=4867875" class="parent">Home</a>
|
</li>
<li class="item parent">
<a href="/article.asp?aid=4867904" class="parent">Services Registration</a>
|
</li>
<li class="item parent selected">
<a href="/article.asp?aid=4867926" class="parent selected">Yizkor Booklet</a>
|
</li>
<li class="item parent">
<a href="/article.asp?aid=6584133" class="parent">Rosh Hashana Dinner</a>
|
</li>
<li class="item parent">
<a href="/article.asp?aid=6584147" class="parent">Shofar for the Family</a>
</li>

</ul>
</div>
</div>



</div>
<div id="chabad_body_content">
<div class="chabad_left_column">
<div actions="edit,delete" name="content_area" detached="true" id="ContentArea" type="static" class="chabad_left_column"><div id="content_page" class="content_page"><!-- END HEADER -->
			
			
			<div class="clearfix bh mobile-only align_right">ב"ה</div>
			
				<div class="master-content-wrapper " >
					

<header class="article-header cf ">
	
	
			<h1 class="article-header__title js-article-title js-page-title">Yizkor Booklet</h1>
		
			<div>
				
			</div>
		
</header>
				</div>
			
			<div class="body_wrapper clearfix co_body">
				<div class="" id="co_body_container">
					
					<div id="ContentBody">
						
						
							<div class="content-area-parent no_margin">
								
	<div id="cco_body">
		<div class="content  no_margin no_overflow" id="co_content_container">
			
			
	

	<article class="content js-content" >
	


		<div class="notice">
			<div class="h1">This form is currently closed.</div>
		</div>
	<div id="formContainer"><div class='has-inactive-form'><script type="text/javascript">var defaultCurrency = { value: 'USD', symbol: '$'};
$j(function(){
window.multiplier = 0;
window.formJson = Object.extend([{"form_height":497,"1_text":"Image","1_message":"","1_src":"https://w2.chabad.org/media/images/569/RrSp5692555.jpg","1_link":"","1_target":"_blank","1_height":161,"1_width":660,"1_align":"Left","1_description":"","1_name":"image","1_qid":1,"1_type":"control_image","1_order":1,"44_text":"\u003cp\u003e\u003ca href=\"https://www.jewishcarrollcounty.com/library/article_cdo/aid/266275/jewish/Death-Mourning.htm\"\u003e\u003cimg src=\"https://w3.chabad.org/media/images/569/JKeA5692896.jpg\" border=\"0\" alt=\"\"\u003e\u003c/a\u003e\u003c/p\u003e","44_name":"doubleclickTo44","44_qid":44,"44_type":"control_text","44_order":2,"45_text":"Your Information","45_subHeader":"","45_headerType":"Default","45_name":"clickTo45","45_qid":45,"45_type":"control_head","45_order":3,"46_text":"Full Name","46_message":"","46_labelAlign":"Auto","46_required":"Yes","46_prefix":"No","46_suffix":"No","46_middle":"No","46_description":"","46_sublabels":{"prefix":"Prefix","first":"First Name","middle":"Middle Name","last":"Last Name","suffix":"Suffix"},"46_readonly":"No","46_name":"fullName46","46_qid":46,"46_type":"control_fullname","46_order":4,"47_receivesReceipts":"Yes","47_text":"E-mail","47_message":"","47_labelAlign":"Auto","47_required":"Yes","47_size":30,"47_validation":"Email","47_maxsize":"","47_defaultValue":"","47_subLabel":"","47_hint":"ex: myname@example.com","47_description":"","47_confirmation":"No","47_confirmationHint":"Confirm Email","47_readonly":"No","47_name":"email","47_qid":47,"47_type":"control_email","47_order":5,"49_text":"Phone Number","49_message":"","49_labelAlign":"Auto","49_required":"Yes","49_validation":"Numeric","49_countryCode":"No","49_inputMask":"disable","49_inputMaskValue":"(###) ###-####","49_description":"","49_sublabels":{"country":"Country Code","area":"Area Code","phone":"Phone Number","full":"Phone Number"},"49_readonly":"No","49_name":"phoneNumber","49_qid":49,"49_type":"control_phone","49_order":6,"6_text":"Yahrtzeit Dedication Information","6_subHeader":"","6_headerType":"Default","6_name":"clickTo6","6_qid":6,"6_type":"control_head","6_order":7,"3_text":"\u003cp\u003eDEDICATION DEADLINE for inclusion in the Yizkor Booklet is Monday, September 8\u003c/p\u003e\n","3_name":"doubleclickTo","3_qid":3,"3_type":"control_text","3_order":8,"12_text":"","12_message":"","12_labelAlign":"Auto","12_required":"No","12_options":"Please list all my Yahrzeit names from Chabad\u0027s records associated with my family|Please use the following list:","12_special":"None","12_allowOther":"No","12_otherText":"Other","12_calculateOther":"No","12_selected":"","12_spreadCols":"1","12_description":"","12_name":"input12","12_qid":12,"12_type":"control_radio","12_order":9,"17_text":"Name 1","17_subHeader":"","17_headerType":"Small","17_name":"clickTo17","17_qid":17,"17_type":"control_head","17_order":10,"7_text":"Civil Full Name","7_message":"","7_labelAlign":"Auto","7_required":"No","7_prefix":"No","7_suffix":"No","7_middle":"No","7_description":"","7_sublabels":{"prefix":"Prefix","first":"First Name","middle":"Middle Name","last":"Last Name","suffix":"Suffix"},"7_readonly":"No","7_name":"fullName","7_qid":7,"7_type":"control_fullname","7_order":11,"19_text":"Hebrew Name","19_message":"","19_labelAlign":"Auto","19_required":"No","19_size":20,"19_validation":"None","19_maxsize":"","19_inputTextMask":"","19_defaultValue":"","19_subLabel":"","19_hint":" ","19_description":"","19_readonly":"No","19_name":"input19","19_qid":19,"19_type":"control_textbox","19_order":12,"20_text":"Father\u0027s Hebrew Name","20_message":"","20_labelAlign":"Auto","20_required":"No","20_size":20,"20_validation":"None","20_maxsize":"","20_inputTextMask":"","20_defaultValue":"","20_subLabel":"","20_hint":" ","20_description":"","20_readonly":"No","20_name":"input20","20_qid":20,"20_type":"control_textbox","20_order":13,"10_text":"Relationship ","10_message":"Father, mother ect.","10_labelAlign":"Auto","10_required":"No","10_size":20,"10_validation":"None","10_maxsize":"","10_inputTextMask":"","10_defaultValue":"","10_subLabel":"","10_hint":" ","10_description":"","10_readonly":"No","10_name":"input10","10_qid":10,"10_type":"control_textbox","10_order":14,"11_text":"Date of Passing","11_message":"","11_labelAlign":"Auto","11_required":"No","11_format":"mmddyyyy","11_yearFrom":"","11_yearTo":"","11_months":[[],[],[],[],[],[],[],[],[],[],[],[]],"11_description":"","11_sublabels":{"month":"Month","day":"Day","year":"Year"},"11_name":"birthDate","11_qid":11,"11_type":"control_birthdate","11_order":15,"18_text":"Name 2","18_subHeader":"","18_headerType":"Small","18_name":"clickTo18","18_qid":18,"18_type":"control_head","18_order":16,"16_text":"Civil Full Name","16_message":"","16_labelAlign":"Auto","16_required":"No","16_prefix":"No","16_suffix":"No","16_middle":"No","16_description":"","16_sublabels":{"prefix":"Prefix","first":"First Name","middle":"Middle Name","last":"Last Name","suffix":"Suffix"},"16_readonly":"No","16_name":"fullName16","16_qid":16,"16_type":"control_fullname","16_order":17,"25_text":"Hebrew Name","25_message":"","25_labelAlign":"Auto","25_required":"No","25_size":20,"25_validation":"None","25_maxsize":"","25_inputTextMask":"","25_defaultValue":"","25_subLabel":"","25_hint":" ","25_description":"","25_readonly":"No","25_name":"input25","25_qid":25,"25_type":"control_textbox","25_order":18,"26_text":"Father\u0027s Hebrew Name","26_message":"","26_labelAlign":"Auto","26_required":"No","26_size":20,"26_validation":"None","26_maxsize":"","26_inputTextMask":"","26_defaultValue":"","26_subLabel":"","26_hint":" ","26_description":"","26_readonly":"No","26_name":"input26","26_qid":26,"26_type":"control_textbox","26_order":19,"21_text":"Relationship ","21_message":"Father, mother ect.","21_labelAlign":"Auto","21_required":"No","21_size":20,"21_validation":"None","21_maxsize":"","21_inputTextMask":"","21_defaultValue":"","21_subLabel":"","21_hint":" ","21_description":"","21_readonly":"No","21_name":"input21","21_qid":21,"21_type":"control_textbox","21_order":20,"22_text":"Date of Passing","22_message":"","22_labelAlign":"Auto","22_required":"No","22_format":"mmddyyyy","22_yearFrom":"","22_yearTo":"","22_months":[[],[],[],[],[],[],[],[],[],[],[],[]],"22_description":"","22_sublabels":{"month":"Month","day":"Day","year":"Year"},"22_name":"birthDate22","22_qid":22,"22_type":"control_birthdate","22_order":21,"31_text":"Name 3","31_subHeader":"","31_headerType":"Small","31_name":"clickTo31","31_qid":31,"31_type":"control_head","31_order":22,"32_text":"Civil Full Name","32_message":"","32_labelAlign":"Auto","32_required":"No","32_prefix":"No","32_suffix":"No","32_middle":"No","32_description":"","32_sublabels":{"prefix":"Prefix","first":"First Name","middle":"Middle Name","last":"Last Name","suffix":"Suffix"},"32_readonly":"No","32_name":"fullName32","32_qid":32,"32_type":"control_fullname","32_order":23,"33_text":"Hebrew Name","33_message":"","33_labelAlign":"Auto","33_required":"No","33_size":20,"33_validation":"None","33_maxsize":"","33_inputTextMask":"","33_defaultValue":"","33_subLabel":"","33_hint":" ","33_description":"","33_readonly":"No","33_name":"input33","33_qid":33,"33_type":"control_textbox","33_order":24,"9_text":"Father\u0027s Hebrew Name","9_message":"","9_labelAlign":"Auto","9_required":"No","9_size":20,"9_validation":"None","9_maxsize":"","9_inputTextMask":"","9_defaultValue":"","9_subLabel":"","9_hint":" ","9_description":"","9_readonly":"No","9_name":"input9","9_qid":9,"9_type":"control_textbox","9_order":25,"27_text":"Relationship ","27_message":"Father, mother ect.","27_labelAlign":"Auto","27_required":"No","27_size":20,"27_validation":"None","27_maxsize":"","27_inputTextMask":"","27_defaultValue":"","27_subLabel":"","27_hint":" ","27_description":"","27_readonly":"No","27_name":"input27","27_qid":27,"27_type":"control_textbox","27_order":26,"28_text":"Date of Passing","28_message":"","28_labelAlign":"Auto","28_required":"No","28_format":"mmddyyyy","28_yearFrom":"","28_yearTo":"","28_months":[[],[],[],[],[],[],[],[],[],[],[],[]],"28_description":"","28_sublabels":{"month":"Month","day":"Day","year":"Year"},"28_name":"birthDate28","28_qid":28,"28_type":"control_birthdate","28_order":27,"23_text":"Name 4","23_subHeader":"","23_headerType":"Small","23_name":"clickTo23","23_qid":23,"23_type":"control_head","23_order":28,"24_text":"Civil Full Name","24_message":"","24_labelAlign":"Auto","24_required":"No","24_prefix":"No","24_suffix":"No","24_middle":"No","24_description":"","24_sublabels":{"prefix":"Prefix","first":"First Name","middle":"Middle Name","last":"Last Name","suffix":"Suffix"},"24_readonly":"No","24_name":"fullName24","24_qid":24,"24_type":"control_fullname","24_order":29,"8_text":"Hebrew Name","8_message":"","8_labelAlign":"Auto","8_required":"No","8_size":20,"8_validation":"None","8_maxsize":"","8_inputTextMask":"","8_defaultValue":"","8_subLabel":"","8_hint":" ","8_description":"","8_readonly":"No","8_name":"input8","8_qid":8,"8_type":"control_textbox","8_order":30,"34_text":"Father\u0027s Hebrew Name","34_message":"","34_labelAlign":"Auto","34_required":"No","34_size":20,"34_validation":"None","34_maxsize":"","34_inputTextMask":"","34_defaultValue":"","34_subLabel":"","34_hint":" ","34_description":"","34_readonly":"No","34_name":"input34","34_qid":34,"34_type":"control_textbox","34_order":31,"35_text":"Relationship ","35_message":"Father, mother ect.","35_labelAlign":"Auto","35_required":"No","35_size":20,"35_validation":"None","35_maxsize":"","35_inputTextMask":"","35_defaultValue":"","35_subLabel":"","35_hint":" ","35_description":"","35_readonly":"No","35_name":"input35","35_qid":35,"35_type":"control_textbox","35_order":32,"36_text":"Date of Passing","36_message":"","36_labelAlign":"Auto","36_required":"No","36_format":"mmddyyyy","36_yearFrom":"","36_yearTo":"","36_months":[[],[],[],[],[],[],[],[],[],[],[],[]],"36_description":"","36_sublabels":{"month":"Month","day":"Day","year":"Year"},"36_name":"birthDate36","36_qid":36,"36_type":"control_birthdate","36_order":33,"37_text":"Name 5","37_subHeader":"","37_headerType":"Small","37_name":"clickTo37","37_qid":37,"37_type":"control_head","37_order":34,"38_text":"Civil Full Name","38_message":"","38_labelAlign":"Auto","38_required":"No","38_prefix":"No","38_suffix":"No","38_middle":"No","38_description":"","38_sublabels":{"prefix":"Prefix","first":"First Name","middle":"Middle Name","last":"Last Name","suffix":"Suffix"},"38_readonly":"No","38_name":"fullName38","38_qid":38,"38_type":"control_fullname","38_order":35,"39_text":"Hebrew Name","39_message":"","39_labelAlign":"Auto","39_required":"No","39_size":20,"39_validation":"None","39_maxsize":"","39_inputTextMask":"","39_defaultValue":"","39_subLabel":"","39_hint":" ","39_description":"","39_readonly":"No","39_name":"input39","39_qid":39,"39_type":"control_textbox","39_order":36,"40_text":"Father\u0027s Hebrew Name","40_message":"","40_labelAlign":"Auto","40_required":"No","40_size":20,"40_validation":"None","40_maxsize":"","40_inputTextMask":"","40_defaultValue":"","40_subLabel":"","40_hint":" ","40_description":"","40_readonly":"No","40_name":"input40","40_qid":40,"40_type":"control_textbox","40_order":37,"41_text":"Relationship ","41_message":"Father, mother ect.","41_labelAlign":"Auto","41_required":"No","41_size":20,"41_validation":"None","41_maxsize":"","41_inputTextMask":"","41_defaultValue":"","41_subLabel":"","41_hint":" ","41_description":"","41_readonly":"No","41_name":"input41","41_qid":41,"41_type":"control_textbox","41_order":38,"42_text":"Date of Passing","42_message":"","42_labelAlign":"Auto","42_required":"No","42_format":"mmddyyyy","42_yearFrom":"","42_yearTo":"","42_months":[[],[],[],[],[],[],[],[],[],[],[],[]],"42_description":"","42_sublabels":{"month":"Month","day":"Day","year":"Year"},"42_name":"birthDate42","42_qid":42,"42_type":"control_birthdate","42_order":39,"29_text":"\tPlease use field below for any relevant notes:","29_message":"","29_labelAlign":"Auto","29_required":"No","29_cols":40,"29_rows":6,"29_validation":"None","29_entryLimit":"None-0","29_maxsize":"","29_defaultValue":"","29_subLabel":"","29_hint":"","29_description":"","29_readonly":"No","29_wysiwyg":"Disable","29_name":"input29","29_qid":29,"29_type":"control_textarea","29_order":40,"51_text":"\u003cp\u003ePlease consider making a donation to Chabad\u0026nbsp;in memory of your loved one/s.\u003c/p\u003e\n","51_name":"doubleclickTo51","51_qid":51,"51_type":"control_text","51_order":41,"50_text":"Donation Amount","50_message":"","50_labelAlign":"Auto","50_required":"No","50_options":"50|75|100","50_special":"None","50_allowOther":"No","50_otherText":"Other","50_selected":"","50_spreadCols":"3","50_description":"","50_mode":"textbox","50_name":"input50","50_qid":50,"50_type":"control_amount","50_order":42,"15_labelAlign":"Auto","15_text":"Total","15_partialPayEnabled":"No","15_partialPayType":"dollar","15_partialPayMinimum":0,"15_required":"No","15_offsetGiftEnabled":"No","15_offsetGift":3,"15_name":"total","15_qid":15,"15_type":"control_totalamount","15_order":43,"30_text":"Payment","30_message":"","30_labelAlign":"Auto","30_required":"No","30_duplicatable":false,"30_selectedCountry":"","30_description":"","30_sublabels":{"cc_firstName":"First Name","cc_lastName":"Last Name","cc_type":"Credit Card Type","cc_number":"Credit Card Number","cc_ccv":"Security Code","cc_nameOnCard":"Name on Card","cc_IdNumber":"Israel Identity Number","cc_exp_month":"Expiration Month","cc_exp_year":"Expiration Year","eCheck_bankName":"Bank Name","eCheck_routingNumber":"Routing Number","eCheck_accountNumber":"Account Number","eCheck_accountType":"Account Type","addr_line1":"Street Address","addr_line2":"Street Address Line 2","city":"City","state":"State / Province","postal":"Postal / Zip Code","country":"Country"},"30_name":"payment","30_qid":30,"30_type":"control_payform","30_order":44,"30_options":{"currency":"default","creditCard":{"value":"Credit Card","enabled":true,"fields":[{"name":"ccv","value":"CCV","enabled":true},{"name":"nameOnCard","value":"Name on Card","enabled":true},{"name":"billingAddress","value":"Billing Address","enabled":true},{"name":"israelIdentityNumber","value":"Israel Identity Number","enabled":true}],"processorIndex":0,"type":[{"name":"Visa","value":"Visa","enabled":true},{"name":"Mastercard","value":"MasterCard","enabled":true},{"name":"Amex","value":"American Express","enabled":true},{"name":"Discover","value":"Discover","enabled":true},{"name":"Isracard","value":"Isracard","enabled":false}],"payMe":false},"paypal":{"value":"Paypal","enabled":false,"processorIndex":null},"eCheck":{"value":"eCheck","enabled":false},"other":{"value":"Other","enabled":true,"altText":"Check","message":""}},"48_text":"Optin","48_labelAlign":"Auto","48_description":"","48_required":"No","48_list":"-1","48_duplicatable":false,"48_name":"optin","48_qid":48,"48_type":"control_optin","48_order":45,"form_title":"Click to edit this text...","form_pagetitle":"Form","form_styles":"nova","form_font":"","form_fontsize":"14","form_fontcolor":"","form_optioncolor":"","form_lineSpacing":"12","form_background":"","form_formWidth":"685","form_labelWidth":"150","form_alignment":"Left","form_thankurl":"","form_thanktext":"","form_highlightLine":"Enabled","form_activeRedirect":"default","form_sendpostdata":"No","form_unique":"None","form_uniqueField":"\u003cField Id\u003e","form_status":"Enabled","form_injectCSS":"","form_hideMailEmptyFields":"disable","form_showProgressBar":"disable","form_formStrings":[{"alphabetic":"This field can only contain letters","alphanumeric":"This field can only contain letters and numbers.","confirmClearForm":"Are you sure you want to clear the form?","confirmEmail":"E-mail does not match","email":"Enter a valid e-mail address","generalError":"There are errors on the form. Please fix them before continuing.","generalPageError":"There are errors on this page. Please fix them before continuing.","gradingScoreError":"Score total should only be less than or equal to","incompleteFields":"There are incomplete required fields. Please complete them.","inputCarretErrorA":"Input should not be less than the minimum value:","inputCarretErrorB":"Input should not be greater than the maximum value:","lessThan":"Your score should be less than or equal to","maxDigitsError":"The maximum digits allowed is","maxSelectionsError":"The maximum number of selections allowed is","minSelectionsError":"The minimum required number of selections is","multipleFileUploads_emptyError":"{file} is empty, please select files again without it.","multipleFileUploads_minSizeError":"{file} is too small, minimum file size is {minSizeLimit}.","multipleFileUploads_onLeave":"The files are being uploaded, if you leave now the upload will be cancelled.","multipleFileUploads_sizeError":"{file} is too large, maximum file size is {sizeLimit}.","multipleFileUploads_typeError":"{file} has invalid extension. Only {extensions} are allowed.","numeric":"This field can only contain numeric values","pastDatesDisallowed":"Date must not be in the past.","pleaseWait":"Please wait...","required":"This field is required.","requireEveryRow":"Every row is required.","requireOne":"At least one field required.","submissionLimit":"Sorry! Only one entry is allowed.  Multiple submissions are disabled for this form.","uploadExtensions":"You can only upload following files:","uploadFilesize":"File size cannot be bigger than:"}],"form_limitSubmission":"No Limit","form_expireDate":"No Limit","form_messageOfLimitedForm":"This form is currently unavailable!","form_emails":[],"form_language":"","form_sendEmail":"Yes","form_style":"Default","form_theme":"nova","form_id":4867926,"form_formStringsChanged":"yes","form_slug":4867926,"form_stopHighlight":"Yes"}][0] || {}, window.formJson || {});
window.isSecureForm = true
});

			if (typeof(Userform) ==='undefined')
			{
				Userform={init:function(args){
					$j(function(){
						Userform.init.apply(Userform, [args]);
					})
				},
				setConditions:function(args){
					$j(function(){
						Userform.setConditions.apply(Userform, [args]);
					})
				}};
			}
</script><script type="text/javascript">
   Userform.init(function(){
      $('input_47').hint('ex: myname@example.com');
      Userform.alterTexts({"alphabetic":"This field can only contain letters","alphanumeric":"This field can only contain letters and numbers.","confirmClearForm":"Are you sure you want to clear the form?","confirmEmail":"E-mail does not match","email":"Enter a valid e-mail address","generalError":"There are errors on the form. Please fix them before continuing.","generalPageError":"There are errors on this page. Please fix them before continuing.","gradingScoreError":"Score total should only be less than or equal to","incompleteFields":"There are incomplete required fields. Please complete them.","inputCarretErrorA":"Input should not be less than the minimum value:","inputCarretErrorB":"Input should not be greater than the maximum value:","lessThan":"Your score should be less than or equal to","maxDigitsError":"The maximum digits allowed is","maxSelectionsError":"The maximum number of selections allowed is","minSelectionsError":"The minimum required number of selections is","multipleFileUploads_emptyError":"{file} is empty, please select files again without it.","multipleFileUploads_minSizeError":"{file} is too small, minimum file size is {minSizeLimit}.","multipleFileUploads_onLeave":"The files are being uploaded, if you leave now the upload will be cancelled.","multipleFileUploads_sizeError":"{file} is too large, maximum file size is {sizeLimit}.","multipleFileUploads_typeError":"{file} has invalid extension. Only {extensions} are allowed.","numeric":"This field can only contain numeric values","pastDatesDisallowed":"Date must not be in the past.","pleaseWait":"Please wait...","required":"This field is required.","requireEveryRow":"Every row is required.","requireOne":"At least one field required.","submissionLimit":"Sorry! Only one entry is allowed.  Multiple submissions are disabled for this form.","uploadExtensions":"You can only upload following files:","uploadFilesize":"File size cannot be bigger than:"});
   });
</script>
<style type="text/css" id="GenFormStyles">
    .form-label{
        width:150px !important;
    }
    .form-label-left{
        width:150px !important;
    }
    .form-line{
        padding-top:12px;
        padding-bottom:12px;
    }
    .form-label-right{
        width:150px !important;
    }
    .form-all {
        font-size:14px;
    }
.co_body .content .form-all p {
 font-size:14px;

}
@media screen and (max-width: 600px) {.form-label-left{	float:none;	display:block;}.form-buttons-wrapper.button-align-auto{text-indent: 0!important;}}</style>

<form class="userform-form" action="" method="post" name="form_4867926" id="4867926" accept-charset="utf-8"><input type="hidden" name="formID" value="4867926" /><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"> <img alt="" class="form-image" border="0" src="https://w2.chabad.org/media/images/569/RrSp5692555.jpg" height="161" width="660" /> </div></li><li class="form-line" id="id_44"><div id="cid_44" class="form-input-wide"> <div id="text_44" class="form-html"><p><a href="https://www.jewishcarrollcounty.com/library/article_cdo/aid/266275/jewish/Death-Mourning.htm"><img src="https://w3.chabad.org/media/images/569/JKeA5692896.jpg" border="0" alt="" /></a></p></div> </div></li><li id="cid_45" class="form-input-wide"> <div class="form-header-group"><h2 id="header_45" class="form-header">Your Information</h2></div> </li><li class="form-line" id="id_46"><div class="form-label-left" id="label_46"><label for="input_46"> Full Name<span class="form-required">*</span> </label><label class="label-message" for="input_46"> </label></div><div id="cid_46" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="10" name="q46_fullName46[first]" id="first_46" autocomplete="given-name" />  <label class="form-sub-label" for="first_46" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required]" type="text" size="15" name="q46_fullName46[last]" id="last_46" autocomplete="family-name" />  <label class="form-sub-label" for="last_46" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_47"><div class="form-label-left" id="label_47"><label for="input_47"> E-mail<span class="form-required">*</span> </label><label class="label-message" for="input_47"> </label></div><div id="cid_47" class="form-input"> <input type="email" class=" form-textbox validate[required, Email]" id="input_47" name="q47_email" size="30" value="" autocomplete="email" /> </div></li><li class="form-line" id="id_49"><div class="form-label-left" id="label_49"><label for="input_49"> Phone Number<span class="form-required">*</span> </label><label class="label-message" for="input_49"> </label></div><div id="cid_49" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><input class="form-textbox validate[required, Numeric]" type="tel" name="q49_phoneNumber[area]" id="input_49_area" autocomplete="tel-area-code" maxlength="5" size="3" />  <label class="form-sub-label" for="input_49_area" id="sublabel_area">Area Code</label></span><span class="form-sub-label-container"><input class="form-textbox validate[required, Numeric]" type="tel" name="q49_phoneNumber[phone]" id="input_49_phone" autocomplete="tel-local" size="8" />  <label class="form-sub-label" for="input_49_phone" id="sublabel_phone">Phone Number</label></span></div> </div></li><li id="cid_6" class="form-input-wide"> <div class="form-header-group"><h2 id="header_6" class="form-header">Yahrtzeit Dedication Information</h2></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>DEDICATION DEADLINE for inclusion in the Yizkor Booklet is Monday, September 8</p>
</div> </div></li><li class="form-line" id="id_12"><div class="form-label-left" id="label_12"><label for="input_12">  </label><label class="label-message" for="input_12"> </label></div><div id="cid_12" class="form-input"> <div class="form-single-column"><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_12_0" name="q12_input12" value="Please list all my Yahrzeit names from Chabad's records associated with my family" /><label id="label_input_12_0" for="input_12_0"><span>Please list all my Yahrzeit names from Chabad's records associated with my family</span></label></span><span class="clearfix"></span><span class="form-radio-item clear-left"><input type="radio" class="form-radio" id="input_12_1" name="q12_input12" value="Please use the following list:" /><label id="label_input_12_1" for="input_12_1"><span>Please use the following list:</span></label></span><span class="clearfix"></span></div> </div></li><li id="cid_17" class="form-input-wide"> <div class="form-header-group"><h3 id="header_17" class="form-header">Name 1</h3></div> </li><li class="form-line" id="id_7"><div class="form-label-left" id="label_7"><label for="input_7"> Civil Full Name </label><label class="label-message" for="input_7"> </label></div><div id="cid_7" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q7_fullName[first]" id="first_7" autocomplete="given-name" />  <label class="form-sub-label" for="first_7" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="15" name="q7_fullName[last]" id="last_7" autocomplete="family-name" />  <label class="form-sub-label" for="last_7" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_19"><div class="form-label-left" id="label_19"><label for="input_19"> Hebrew Name </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"> Father's Hebrew Name </label><label class="label-message" for="input_20"> </label></div><div id="cid_20" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_20" name="q20_input20" size="20" value="" /> </div></li><li class="form-line" id="id_10"><div class="form-label-left" id="label_10"><label for="input_10"> Relationship  </label><label class="label-message" for="input_10"> Father, mother ect.</label></div><div id="cid_10" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_10" name="q10_input10" size="20" value="" /> </div></li><li class="form-line" id="id_11"><div class="form-label-left" id="label_11"><label for="input_11"> Date of Passing </label><label class="label-message" for="input_11"> </label></div><div id="cid_11" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><select class="form-dropdown" name="q11_birthDate[month]" id="input_11_month"><option></option><option value="1">1 - January</option><option value="2">2 - February</option><option value="3">3 - March</option><option value="4">4 - April</option><option value="5">5 - May</option><option value="6">6 - June</option><option value="7">7 - July</option><option value="8">8 - August</option><option value="9">9 - September</option><option value="10">10 - October</option><option value="11">11 - November</option><option value="12">12 - December</option></select>  <label class="form-sub-label" for="input_11_month" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><select class="form-dropdown" name="q11_birthDate[day]" id="input_11_day"><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 value="11">11</option><option value="12">12</option><option value="13">13</option><option value="14">14</option><option value="15">15</option><option value="16">16</option><option value="17">17</option><option value="18">18</option><option value="19">19</option><option value="20">20</option><option value="21">21</option><option value="22">22</option><option value="23">23</option><option value="24">24</option><option value="25">25</option><option value="26">26</option><option value="27">27</option><option value="28">28</option><option value="29">29</option><option value="30">30</option><option value="31">31</option></select>  <label class="form-sub-label" for="input_11_day" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><select class="form-dropdown" name="q11_birthDate[year]" id="input_11_year"><option></option><option value="2025">2025</option><option value="2024">2024</option><option value="2023">2023</option><option value="2022">2022</option><option value="2021">2021</option><option value="2020">2020</option><option value="2019">2019</option><option value="2018">2018</option><option value="2017">2017</option><option value="2016">2016</option><option value="2015">2015</option><option value="2014">2014</option><option value="2013">2013</option><option value="2012">2012</option><option value="2011">2011</option><option value="2010">2010</option><option value="2009">2009</option><option value="2008">2008</option><option value="2007">2007</option><option value="2006">2006</option><option value="2005">2005</option><option value="2004">2004</option><option value="2003">2003</option><option value="2002">2002</option><option value="2001">2001</option><option value="2000">2000</option><option value="1999">1999</option><option value="1998">1998</option><option value="1997">1997</option><option value="1996">1996</option><option value="1995">1995</option><option value="1994">1994</option><option value="1993">1993</option><option value="1992">1992</option><option value="1991">1991</option><option value="1990">1990</option><option value="1989">1989</option><option value="1988">1988</option><option value="1987">1987</option><option value="1986">1986</option><option value="1985">1985</option><option value="1984">1984</option><option value="1983">1983</option><option value="1982">1982</option><option value="1981">1981</option><option value="1980">1980</option><option value="1979">1979</option><option value="1978">1978</option><option value="1977">1977</option><option value="1976">1976</option><option value="1975">1975</option><option value="1974">1974</option><option value="1973">1973</option><option value="1972">1972</option><option value="1971">1971</option><option value="1970">1970</option><option value="1969">1969</option><option value="1968">1968</option><option value="1967">1967</option><option value="1966">1966</option><option value="1965">1965</option><option value="1964">1964</option><option value="1963">1963</option><option value="1962">1962</option><option value="1961">1961</option><option value="1960">1960</option><option value="1959">1959</option><option value="1958">1958</option><option value="1957">1957</option><option value="1956">1956</option><option value="1955">1955</option><option value="1954">1954</option><option value="1953">1953</option><option value="1952">1952</option><option value="1951">1951</option><option value="1950">1950</option><option value="1949">1949</option><option value="1948">1948</option><option value="1947">1947</option><option value="1946">1946</option><option value="1945">1945</option><option value="1944">1944</option><option value="1943">1943</option><option value="1942">1942</option><option value="1941">1941</option><option value="1940">1940</option><option value="1939">1939</option><option value="1938">1938</option><option value="1937">1937</option><option value="1936">1936</option><option value="1935">1935</option><option value="1934">1934</option><option value="1933">1933</option><option value="1932">1932</option><option value="1931">1931</option><option value="1930">1930</option><option value="1929">1929</option><option value="1928">1928</option><option value="1927">1927</option><option value="1926">1926</option><option value="1925">1925</option><option value="1924">1924</option><option value="1923">1923</option><option value="1922">1922</option><option value="1921">1921</option><option value="1920">1920</option></select>  <label class="form-sub-label" for="input_11_year" id="sublabel_year">Year</label></span></div> </div></li><li id="cid_18" class="form-input-wide"> <div class="form-header-group"><h3 id="header_18" class="form-header">Name 2</h3></div> </li><li class="form-line" id="id_16"><div class="form-label-left" id="label_16"><label for="input_16"> Civil Full Name </label><label class="label-message" for="input_16"> </label></div><div id="cid_16" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q16_fullName16[first]" id="first_16" autocomplete="given-name" />  <label class="form-sub-label" for="first_16" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="15" name="q16_fullName16[last]" id="last_16" autocomplete="family-name" />  <label class="form-sub-label" for="last_16" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_25"><div class="form-label-left" id="label_25"><label for="input_25"> Hebrew Name </label><label class="label-message" for="input_25"> </label></div><div id="cid_25" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_25" name="q25_input25" size="20" value="" /> </div></li><li class="form-line" id="id_26"><div class="form-label-left" id="label_26"><label for="input_26"> Father's Hebrew Name </label><label class="label-message" for="input_26"> </label></div><div id="cid_26" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_26" name="q26_input26" size="20" value="" /> </div></li><li class="form-line" id="id_21"><div class="form-label-left" id="label_21"><label for="input_21"> Relationship  </label><label class="label-message" for="input_21"> Father, mother ect.</label></div><div id="cid_21" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_21" name="q21_input21" size="20" value="" /> </div></li><li class="form-line" id="id_22"><div class="form-label-left" id="label_22"><label for="input_22"> Date of Passing </label><label class="label-message" for="input_22"> </label></div><div id="cid_22" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><select class="form-dropdown" name="q22_birthDate22[month]" id="input_22_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_22_month" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><select class="form-dropdown" name="q22_birthDate22[day]" id="input_22_day"><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 value="11">11</option><option value="12">12</option><option value="13">13</option><option value="14">14</option><option value="15">15</option><option value="16">16</option><option value="17">17</option><option value="18">18</option><option value="19">19</option><option value="20">20</option><option value="21">21</option><option value="22">22</option><option value="23">23</option><option value="24">24</option><option value="25">25</option><option value="26">26</option><option value="27">27</option><option value="28">28</option><option value="29">29</option><option value="30">30</option><option value="31">31</option></select>  <label class="form-sub-label" for="input_22_day" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><select class="form-dropdown" name="q22_birthDate22[year]" id="input_22_year"><option></option><option value="2025">2025</option><option value="2024">2024</option><option value="2023">2023</option><option value="2022">2022</option><option value="2021">2021</option><option value="2020">2020</option><option value="2019">2019</option><option value="2018">2018</option><option value="2017">2017</option><option value="2016">2016</option><option value="2015">2015</option><option value="2014">2014</option><option value="2013">2013</option><option value="2012">2012</option><option value="2011">2011</option><option value="2010">2010</option><option value="2009">2009</option><option value="2008">2008</option><option value="2007">2007</option><option value="2006">2006</option><option value="2005">2005</option><option value="2004">2004</option><option value="2003">2003</option><option value="2002">2002</option><option value="2001">2001</option><option value="2000">2000</option><option value="1999">1999</option><option value="1998">1998</option><option value="1997">1997</option><option value="1996">1996</option><option value="1995">1995</option><option value="1994">1994</option><option value="1993">1993</option><option value="1992">1992</option><option value="1991">1991</option><option value="1990">1990</option><option value="1989">1989</option><option value="1988">1988</option><option value="1987">1987</option><option value="1986">1986</option><option value="1985">1985</option><option value="1984">1984</option><option value="1983">1983</option><option value="1982">1982</option><option value="1981">1981</option><option value="1980">1980</option><option value="1979">1979</option><option value="1978">1978</option><option value="1977">1977</option><option value="1976">1976</option><option value="1975">1975</option><option value="1974">1974</option><option value="1973">1973</option><option value="1972">1972</option><option value="1971">1971</option><option value="1970">1970</option><option value="1969">1969</option><option value="1968">1968</option><option value="1967">1967</option><option value="1966">1966</option><option value="1965">1965</option><option value="1964">1964</option><option value="1963">1963</option><option value="1962">1962</option><option value="1961">1961</option><option value="1960">1960</option><option value="1959">1959</option><option value="1958">1958</option><option value="1957">1957</option><option value="1956">1956</option><option value="1955">1955</option><option value="1954">1954</option><option value="1953">1953</option><option value="1952">1952</option><option value="1951">1951</option><option value="1950">1950</option><option value="1949">1949</option><option value="1948">1948</option><option value="1947">1947</option><option value="1946">1946</option><option value="1945">1945</option><option value="1944">1944</option><option value="1943">1943</option><option value="1942">1942</option><option value="1941">1941</option><option value="1940">1940</option><option value="1939">1939</option><option value="1938">1938</option><option value="1937">1937</option><option value="1936">1936</option><option value="1935">1935</option><option value="1934">1934</option><option value="1933">1933</option><option value="1932">1932</option><option value="1931">1931</option><option value="1930">1930</option><option value="1929">1929</option><option value="1928">1928</option><option value="1927">1927</option><option value="1926">1926</option><option value="1925">1925</option><option value="1924">1924</option><option value="1923">1923</option><option value="1922">1922</option><option value="1921">1921</option><option value="1920">1920</option></select>  <label class="form-sub-label" for="input_22_year" id="sublabel_year">Year</label></span></div> </div></li><li id="cid_31" class="form-input-wide"> <div class="form-header-group"><h3 id="header_31" class="form-header">Name 3</h3></div> </li><li class="form-line" id="id_32"><div class="form-label-left" id="label_32"><label for="input_32"> Civil Full Name </label><label class="label-message" for="input_32"> </label></div><div id="cid_32" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q32_fullName32[first]" id="first_32" autocomplete="given-name" />  <label class="form-sub-label" for="first_32" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="15" name="q32_fullName32[last]" id="last_32" autocomplete="family-name" />  <label class="form-sub-label" for="last_32" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_33"><div class="form-label-left" id="label_33"><label for="input_33"> Hebrew Name </label><label class="label-message" for="input_33"> </label></div><div id="cid_33" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_33" name="q33_input33" size="20" value="" /> </div></li><li class="form-line" id="id_9"><div class="form-label-left" id="label_9"><label for="input_9"> Father's Hebrew Name </label><label class="label-message" for="input_9"> </label></div><div id="cid_9" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_9" name="q9_input9" size="20" value="" /> </div></li><li class="form-line" id="id_27"><div class="form-label-left" id="label_27"><label for="input_27"> Relationship  </label><label class="label-message" for="input_27"> Father, mother ect.</label></div><div id="cid_27" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_27" name="q27_input27" size="20" value="" /> </div></li><li class="form-line" id="id_28"><div class="form-label-left" id="label_28"><label for="input_28"> Date of Passing </label><label class="label-message" for="input_28"> </label></div><div id="cid_28" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><select class="form-dropdown" name="q28_birthDate28[month]" id="input_28_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_28_month" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><select class="form-dropdown" name="q28_birthDate28[day]" id="input_28_day"><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 value="11">11</option><option value="12">12</option><option value="13">13</option><option value="14">14</option><option value="15">15</option><option value="16">16</option><option value="17">17</option><option value="18">18</option><option value="19">19</option><option value="20">20</option><option value="21">21</option><option value="22">22</option><option value="23">23</option><option value="24">24</option><option value="25">25</option><option value="26">26</option><option value="27">27</option><option value="28">28</option><option value="29">29</option><option value="30">30</option><option value="31">31</option></select>  <label class="form-sub-label" for="input_28_day" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><select class="form-dropdown" name="q28_birthDate28[year]" id="input_28_year"><option></option><option value="2025">2025</option><option value="2024">2024</option><option value="2023">2023</option><option value="2022">2022</option><option value="2021">2021</option><option value="2020">2020</option><option value="2019">2019</option><option value="2018">2018</option><option value="2017">2017</option><option value="2016">2016</option><option value="2015">2015</option><option value="2014">2014</option><option value="2013">2013</option><option value="2012">2012</option><option value="2011">2011</option><option value="2010">2010</option><option value="2009">2009</option><option value="2008">2008</option><option value="2007">2007</option><option value="2006">2006</option><option value="2005">2005</option><option value="2004">2004</option><option value="2003">2003</option><option value="2002">2002</option><option value="2001">2001</option><option value="2000">2000</option><option value="1999">1999</option><option value="1998">1998</option><option value="1997">1997</option><option value="1996">1996</option><option value="1995">1995</option><option value="1994">1994</option><option value="1993">1993</option><option value="1992">1992</option><option value="1991">1991</option><option value="1990">1990</option><option value="1989">1989</option><option value="1988">1988</option><option value="1987">1987</option><option value="1986">1986</option><option value="1985">1985</option><option value="1984">1984</option><option value="1983">1983</option><option value="1982">1982</option><option value="1981">1981</option><option value="1980">1980</option><option value="1979">1979</option><option value="1978">1978</option><option value="1977">1977</option><option value="1976">1976</option><option value="1975">1975</option><option value="1974">1974</option><option value="1973">1973</option><option value="1972">1972</option><option value="1971">1971</option><option value="1970">1970</option><option value="1969">1969</option><option value="1968">1968</option><option value="1967">1967</option><option value="1966">1966</option><option value="1965">1965</option><option value="1964">1964</option><option value="1963">1963</option><option value="1962">1962</option><option value="1961">1961</option><option value="1960">1960</option><option value="1959">1959</option><option value="1958">1958</option><option value="1957">1957</option><option value="1956">1956</option><option value="1955">1955</option><option value="1954">1954</option><option value="1953">1953</option><option value="1952">1952</option><option value="1951">1951</option><option value="1950">1950</option><option value="1949">1949</option><option value="1948">1948</option><option value="1947">1947</option><option value="1946">1946</option><option value="1945">1945</option><option value="1944">1944</option><option value="1943">1943</option><option value="1942">1942</option><option value="1941">1941</option><option value="1940">1940</option><option value="1939">1939</option><option value="1938">1938</option><option value="1937">1937</option><option value="1936">1936</option><option value="1935">1935</option><option value="1934">1934</option><option value="1933">1933</option><option value="1932">1932</option><option value="1931">1931</option><option value="1930">1930</option><option value="1929">1929</option><option value="1928">1928</option><option value="1927">1927</option><option value="1926">1926</option><option value="1925">1925</option><option value="1924">1924</option><option value="1923">1923</option><option value="1922">1922</option><option value="1921">1921</option><option value="1920">1920</option></select>  <label class="form-sub-label" for="input_28_year" id="sublabel_year">Year</label></span></div> </div></li><li id="cid_23" class="form-input-wide"> <div class="form-header-group"><h3 id="header_23" class="form-header">Name 4</h3></div> </li><li class="form-line" id="id_24"><div class="form-label-left" id="label_24"><label for="input_24"> Civil Full Name </label><label class="label-message" for="input_24"> </label></div><div id="cid_24" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q24_fullName24[first]" id="first_24" autocomplete="given-name" />  <label class="form-sub-label" for="first_24" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="15" name="q24_fullName24[last]" id="last_24" autocomplete="family-name" />  <label class="form-sub-label" for="last_24" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_8"><div class="form-label-left" id="label_8"><label for="input_8"> Hebrew Name </label><label class="label-message" for="input_8"> </label></div><div id="cid_8" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_8" name="q8_input8" size="20" value="" /> </div></li><li class="form-line" id="id_34"><div class="form-label-left" id="label_34"><label for="input_34"> Father's Hebrew Name </label><label class="label-message" for="input_34"> </label></div><div id="cid_34" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_34" name="q34_input34" size="20" value="" /> </div></li><li class="form-line" id="id_35"><div class="form-label-left" id="label_35"><label for="input_35"> Relationship  </label><label class="label-message" for="input_35"> Father, mother ect.</label></div><div id="cid_35" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_35" name="q35_input35" size="20" value="" /> </div></li><li class="form-line" id="id_36"><div class="form-label-left" id="label_36"><label for="input_36"> Date of Passing </label><label class="label-message" for="input_36"> </label></div><div id="cid_36" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><select class="form-dropdown" name="q36_birthDate36[month]" id="input_36_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_36_month" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><select class="form-dropdown" name="q36_birthDate36[day]" id="input_36_day"><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 value="11">11</option><option value="12">12</option><option value="13">13</option><option value="14">14</option><option value="15">15</option><option value="16">16</option><option value="17">17</option><option value="18">18</option><option value="19">19</option><option value="20">20</option><option value="21">21</option><option value="22">22</option><option value="23">23</option><option value="24">24</option><option value="25">25</option><option value="26">26</option><option value="27">27</option><option value="28">28</option><option value="29">29</option><option value="30">30</option><option value="31">31</option></select>  <label class="form-sub-label" for="input_36_day" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><select class="form-dropdown" name="q36_birthDate36[year]" id="input_36_year"><option></option><option value="2025">2025</option><option value="2024">2024</option><option value="2023">2023</option><option value="2022">2022</option><option value="2021">2021</option><option value="2020">2020</option><option value="2019">2019</option><option value="2018">2018</option><option value="2017">2017</option><option value="2016">2016</option><option value="2015">2015</option><option value="2014">2014</option><option value="2013">2013</option><option value="2012">2012</option><option value="2011">2011</option><option value="2010">2010</option><option value="2009">2009</option><option value="2008">2008</option><option value="2007">2007</option><option value="2006">2006</option><option value="2005">2005</option><option value="2004">2004</option><option value="2003">2003</option><option value="2002">2002</option><option value="2001">2001</option><option value="2000">2000</option><option value="1999">1999</option><option value="1998">1998</option><option value="1997">1997</option><option value="1996">1996</option><option value="1995">1995</option><option value="1994">1994</option><option value="1993">1993</option><option value="1992">1992</option><option value="1991">1991</option><option value="1990">1990</option><option value="1989">1989</option><option value="1988">1988</option><option value="1987">1987</option><option value="1986">1986</option><option value="1985">1985</option><option value="1984">1984</option><option value="1983">1983</option><option value="1982">1982</option><option value="1981">1981</option><option value="1980">1980</option><option value="1979">1979</option><option value="1978">1978</option><option value="1977">1977</option><option value="1976">1976</option><option value="1975">1975</option><option value="1974">1974</option><option value="1973">1973</option><option value="1972">1972</option><option value="1971">1971</option><option value="1970">1970</option><option value="1969">1969</option><option value="1968">1968</option><option value="1967">1967</option><option value="1966">1966</option><option value="1965">1965</option><option value="1964">1964</option><option value="1963">1963</option><option value="1962">1962</option><option value="1961">1961</option><option value="1960">1960</option><option value="1959">1959</option><option value="1958">1958</option><option value="1957">1957</option><option value="1956">1956</option><option value="1955">1955</option><option value="1954">1954</option><option value="1953">1953</option><option value="1952">1952</option><option value="1951">1951</option><option value="1950">1950</option><option value="1949">1949</option><option value="1948">1948</option><option value="1947">1947</option><option value="1946">1946</option><option value="1945">1945</option><option value="1944">1944</option><option value="1943">1943</option><option value="1942">1942</option><option value="1941">1941</option><option value="1940">1940</option><option value="1939">1939</option><option value="1938">1938</option><option value="1937">1937</option><option value="1936">1936</option><option value="1935">1935</option><option value="1934">1934</option><option value="1933">1933</option><option value="1932">1932</option><option value="1931">1931</option><option value="1930">1930</option><option value="1929">1929</option><option value="1928">1928</option><option value="1927">1927</option><option value="1926">1926</option><option value="1925">1925</option><option value="1924">1924</option><option value="1923">1923</option><option value="1922">1922</option><option value="1921">1921</option><option value="1920">1920</option></select>  <label class="form-sub-label" for="input_36_year" id="sublabel_year">Year</label></span></div> </div></li><li id="cid_37" class="form-input-wide"> <div class="form-header-group"><h3 id="header_37" class="form-header">Name 5</h3></div> </li><li class="form-line" id="id_38"><div class="form-label-left" id="label_38"><label for="input_38"> Civil Full Name </label><label class="label-message" for="input_38"> </label></div><div id="cid_38" class="form-input"> <span class="form-sub-label-container"><input class="form-textbox" type="text" size="10" name="q38_fullName38[first]" id="first_38" autocomplete="given-name" />  <label class="form-sub-label" for="first_38" id="sublabel_first">First Name</label></span><span class="form-sub-label-container"><input class="form-textbox" type="text" size="15" name="q38_fullName38[last]" id="last_38" autocomplete="family-name" />  <label class="form-sub-label" for="last_38" id="sublabel_last">Last Name</label></span> </div></li><li class="form-line" id="id_39"><div class="form-label-left" id="label_39"><label for="input_39"> Hebrew Name </label><label class="label-message" for="input_39"> </label></div><div id="cid_39" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_39" name="q39_input39" size="20" value="" /> </div></li><li class="form-line" id="id_40"><div class="form-label-left" id="label_40"><label for="input_40"> Father's Hebrew Name </label><label class="label-message" for="input_40"> </label></div><div id="cid_40" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_40" name="q40_input40" size="20" value="" /> </div></li><li class="form-line" id="id_41"><div class="form-label-left" id="label_41"><label for="input_41"> Relationship  </label><label class="label-message" for="input_41"> Father, mother ect.</label></div><div id="cid_41" class="form-input"> <input type="text" class=" form-textbox" data-type="input-textbox" id="input_41" name="q41_input41" size="20" value="" /> </div></li><li class="form-line" id="id_42"><div class="form-label-left" id="label_42"><label for="input_42"> Date of Passing </label><label class="label-message" for="input_42"> </label></div><div id="cid_42" class="form-input"> <div class="dir_ltr"><span class="form-sub-label-container"><select class="form-dropdown" name="q42_birthDate42[month]" id="input_42_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_42_month" id="sublabel_month">Month</label></span><span class="form-sub-label-container"><select class="form-dropdown" name="q42_birthDate42[day]" id="input_42_day"><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 value="11">11</option><option value="12">12</option><option value="13">13</option><option value="14">14</option><option value="15">15</option><option value="16">16</option><option value="17">17</option><option value="18">18</option><option value="19">19</option><option value="20">20</option><option value="21">21</option><option value="22">22</option><option value="23">23</option><option value="24">24</option><option value="25">25</option><option value="26">26</option><option value="27">27</option><option value="28">28</option><option value="29">29</option><option value="30">30</option><option value="31">31</option></select>  <label class="form-sub-label" for="input_42_day" id="sublabel_day">Day</label></span><span class="form-sub-label-container"><select class="form-dropdown" name="q42_birthDate42[year]" id="input_42_year"><option></option><option value="2025">2025</option><option value="2024">2024</option><option value="2023">2023</option><option value="2022">2022</option><option value="2021">2021</option><option value="2020">2020</option><option value="2019">2019</option><option value="2018">2018</option><option value="2017">2017</option><option value="2016">2016</option><option value="2015">2015</option><option value="2014">2014</option><option value="2013">2013</option><option value="2012">2012</option><option value="2011">2011</option><option value="2010">2010</option><option value="2009">2009</option><option value="2008">2008</option><option value="2007">2007</option><option value="2006">2006</option><option value="2005">2005</option><option value="2004">2004</option><option value="2003">2003</option><option value="2002">2002</option><option value="2001">2001</option><option value="2000">2000</option><option value="1999">1999</option><option value="1998">1998</option><option value="1997">1997</option><option value="1996">1996</option><option value="1995">1995</option><option value="1994">1994</option><option value="1993">1993</option><option value="1992">1992</option><option value="1991">1991</option><option value="1990">1990</option><option value="1989">1989</option><option value="1988">1988</option><option value="1987">1987</option><option value="1986">1986</option><option value="1985">1985</option><option value="1984">1984</option><option value="1983">1983</option><option value="1982">1982</option><option value="1981">1981</option><option value="1980">1980</option><option value="1979">1979</option><option value="1978">1978</option><option value="1977">1977</option><option value="1976">1976</option><option value="1975">1975</option><option value="1974">1974</option><option value="1973">1973</option><option value="1972">1972</option><option value="1971">1971</option><option value="1970">1970</option><option value="1969">1969</option><option value="1968">1968</option><option value="1967">1967</option><option value="1966">1966</option><option value="1965">1965</option><option value="1964">1964</option><option value="1963">1963</option><option value="1962">1962</option><option value="1961">1961</option><option value="1960">1960</option><option value="1959">1959</option><option value="1958">1958</option><option value="1957">1957</option><option value="1956">1956</option><option value="1955">1955</option><option value="1954">1954</option><option value="1953">1953</option><option value="1952">1952</option><option value="1951">1951</option><option value="1950">1950</option><option value="1949">1949</option><option value="1948">1948</option><option value="1947">1947</option><option value="1946">1946</option><option value="1945">1945</option><option value="1944">1944</option><option value="1943">1943</option><option value="1942">1942</option><option value="1941">1941</option><option value="1940">1940</option><option value="1939">1939</option><option value="1938">1938</option><option value="1937">1937</option><option value="1936">1936</option><option value="1935">1935</option><option value="1934">1934</option><option value="1933">1933</option><option value="1932">1932</option><option value="1931">1931</option><option value="1930">1930</option><option value="1929">1929</option><option value="1928">1928</option><option value="1927">1927</option><option value="1926">1926</option><option value="1925">1925</option><option value="1924">1924</option><option value="1923">1923</option><option value="1922">1922</option><option value="1921">1921</option><option value="1920">1920</option></select>  <label class="form-sub-label" for="input_42_year" id="sublabel_year">Year</label></span></div> </div></li><li class="form-line" id="id_29"><div class="form-label-left" id="label_29"><label for="input_29"> 	Please use field below for any relevant notes: </label><label class="label-message" for="input_29"> </label></div><div id="cid_29" class="form-input"> <textarea id="input_29" class="form-textarea" name="q29_input29" cols="40" rows="6"></textarea> </div></li><li class="form-line" id="id_51"><div id="cid_51" class="form-input-wide"> <div id="text_51" class="form-html"><p>Please consider making a donation to Chabad in memory of your loved one/s.</p>
</div> </div></li><li class="form-line" id="id_50"><div class="form-label-left" id="label_50"><label for="input_50"> Donation Amount </label><label class="label-message" for="input_50"> </label></div><div id="cid_50" class="form-input"> <div class="form-single-column"><span class="form-radio-item simple-mode"><label id="label_input_50" for="input_50"><span>$</span></label><input type="number" class="form-textbox" id="input_50" name="q50_input50" value="" onkeypress="validateNumber(event)" /></span><span class="clearfix"></span></div> </div></li><li class="form-line" id="id_15"><div class="form-label-left" id="label_15"><label for="input_15"> Total </label></div><div id="cid_15" class="form-input"> <div id="total_amount">$0.00 </div> </div></li><li class="form-line" id="id_30"><div class="form-label-left" id="label_30"><label for="input_30"> Payment </label><label class="label-message" for="input_30"> </label></div><div id="cid_30" 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_30_creditCard" name="q30_payment[payment_method]" value="creditCard" onclick="BuildSource.creditCard(this)" /><label for="input_30_creditCard">Credit Card</label> </span><span class="form-radio-item"><input class="paymentMethod form-radio validate[paymentMethod] form-radio" type="radio" id="input_30_other" name="q30_payment[payment_method]" value="other" onclick="BuildSource.other(this)" /><label for="input_30_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="q30_payment[cc_type]" id="input_30_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="q30_payment[cc_number]" id="input_30_cc_number" autocomplete="cc-number" size="20" />  <label class="form-sub-label" for="input_30_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="q30_payment[cc_ccv]" id="input_30_cc_ccv" autocomplete="cc-csc" size="6" />  <label class="form-sub-label" for="input_30_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="q30_payment[cc_nameOnCard]" id="input_30_cc_nameOnCard" autocomplete="cc-name" size="33" />  <label class="form-sub-label" for="input_30_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="q30_payment[cc_exp_month]" id="input_30_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_30_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="q30_payment[cc_exp_year]" id="input_30_cc_exp_year" autocomplete="cc-exp-year"><option></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><option value="2034">2034</option></select>  <label class="form-sub-label" for="input_30_cc_exp_year" id="sublabel_cc_exp_year">Expiration Year</label></span></td></tr></tbody></table></td></tr><tr class="other hide"><td colspan="2"></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="q30_payment[addr_line1]" id="input_30_addr_line1" autocomplete="billing address-line1" />  <label class="form-sub-label" for="input_30_addr_line1" id="sublabel_30_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="q30_payment[city]" id="input_30_city" autocomplete="billing address-level2" />  <label class="form-sub-label" for="input_30_city" id="sublabel_30_city">City</label></span></td><td><span class="form-sub-label-container"><input class="form-textbox form-address-state" type="text" name="q30_payment[state]" id="input_30_state" autocomplete="billing address-level1" />  <label class="form-sub-label" for="input_30_state" id="sublabel_30_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="q30_payment[postal]" id="input_30_postal" size="10" autocomplete="billing postal-code" />  <label class="form-sub-label" for="input_30_postal" id="sublabel_30_postal">Postal / Zip Code</label></span></td><td><span class="form-sub-label-container"><select class="form-dropdown form-address-country" name="q30_payment[country]" id="input_30_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_30_country" id="sublabel_30_country">Country</label></span></td></tr></tbody></table> </div></li><li class="form-line" id="id_48"><div class="form-label-left form-label-hidden" id="label_48"></div><div id="cid_48" 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_48" /><label id="label_input_48" for="input_48">I would like to receive news and updates by email</label></div> </div></li><li style="display:none">Should be Empty: <input type="text" name="website" value="" /></li></ul></div><input type="hidden" id="simple_spc" name="simple_spc" value="4867926" /><script type="text/javascript">document.getElementById("si"+"mple"+"_spc").value = "4867926-4867926";</script><div>


<script>
	var recaptchaIsEnterprise = false;
		 var recaptchaV2Key = "6LcG_TcUAAAAAKAVgwgW39ujc9OCjXSoQYFIA-Su";

</script>

	<input type="hidden" class="js-recaptcha-input" name="cdo-captcha-response" value="" data-div-id="df58a747-53fe-4355-90c7-a4c4c1a23c9c" data-processed="false" />
	<div class="js-recaptcha-wrapper" id="df58a747-53fe-4355-90c7-a4c4c1a23c9c"></div>	
</div></form></div></div>
<div class="center small">
	<img valign="absbottom" src="https://w2.chabad.org/images/global/icons/lock.gif" width="16" height="16" alt="Secure"> This page uses TLS encryption to keep your data secure.
</div>
	<div class="break_floats"></div>
	

<div class="content-footer">
	<!-- END CACHE -->
	
	
	
	
	
</div>
	</article>

		</div>
	</div>
</div>
						
						<div class="break_floats"></div>
						
					</div>
				</div>
				
				
				
			</div>
			
			<!-- BEGIN FOOTER --></div>
<div id="border_bottom"></div>
</div>
</div>
</div>
<!-- END FOOTER -->
		</div>
		
		<aside class="page-tools-sidebar js-page-tools-sidebar hide_for_print">
<div class="page-tools js-page-tools-menu">
<div class="page-tools__section page-tools__section--share">
<a class="page-tools__tool js-share-popup page-tools__tool--facebook" data-share-url="https://www.facebook.com/dialog/share?app_id=188669250943&amp;display=popup&amp;href=https%3a%2f%2fwww.jewishcarrollcounty.com%2ftemplates%2farticlecco_cdo%2faid%2f4867926%2fjewish%2fYizkor-Booklet.htm%23utm_medium%3dpage_tools%26utm_content%3ddesktop%26utm_source%3dFB">
				<i class="fa fa-facebook"></i>
			</a>
<a class="page-tools__tool js-share-popup page-tools__tool--twitter" data-share-url="https://twitter.com/intent/tweet?text=Yizkor+Booklet+-+Chabad+Jewish+Center+Of+Carroll+County&amp;url=https%3a%2f%2fwww.jewishcarrollcounty.com%2ftemplates%2farticlecco_cdo%2faid%2f4867926%2fjewish%2fYizkor-Booklet.htm%23utm_medium%3dpage_tools%26utm_content%3ddesktop%26utm_source%3dtwitter&amp;via=Chabad">
				<i class="fa fa-twitter"></i>
			</a>
<a class="page-tools__tool js-share-popup page-tools__tool--whatsapp d-lg-none js-share-whatsapp" data-share-url="whatsapp://send?text=Yizkor+Booklet+-+Chabad+Jewish+Center+Of+Carroll+County https%3a%2f%2fwww.jewishcarrollcounty.com%2ftemplates%2farticlecco_cdo%2faid%2f4867926%2fjewish%2fYizkor-Booklet.htm%23utm_medium%3dpage_tools%26utm_content%3ddesktop%26utm_source%3dwhatsapp">
				<i class="fa fa-whatsapp">
					<svg xmlns="http://www.w3.org/2000/svg" viewBox="0 0 50 50" fill="#128c7e" width="1em" height="1em"><path d="M25 2C12.318 2 2 12.318 2 25c0 3.96 1.023 7.854 2.963 11.29L2.037 46.73c-.096.343-.003.711.245.966.191.197.451.304.718.304.08 0 .161-.01.24-.029l10.896-2.699C17.463 47.058 21.21 48 25 48c12.682 0 23-10.318 23-23S37.682 2 25 2zm11.57 31.116c-.492 1.362-2.852 2.605-3.986 2.772-1.018.149-2.306.213-3.72-.231-.857-.27-1.957-.628-3.366-1.229-5.923-2.526-9.791-8.415-10.087-8.804-.295-.389-2.411-3.161-2.411-6.03s1.525-4.28 2.067-4.864c.542-.584 1.181-.73 1.575-.73s.787.005 1.132.021c.363.018.85-.137 1.329 1.001.492 1.168 1.673 4.037 1.819 4.33.148.292.246.633.05 1.022s-.294.632-.59.973-.62.76-.886 1.022c-.296.291-.603.606-.259 1.19s1.529 2.493 3.285 4.039c2.255 1.986 4.158 2.602 4.748 2.894.59.292.935.243 1.279-.146.344-.39 1.476-1.703 1.869-2.286s.787-.487 1.329-.292c.542.194 3.445 1.604 4.035 1.896.59.292.984.438 1.132.681.148.242.148 1.41-.344 2.771z"/></svg>
				</i>
			</a>
<a class="page-tools__tool js-share-popup page-tools__tool--pinterest d-none d-lg-block" data-share-url="http://pinterest.com/pin/create/button/?url=https%3a%2f%2fwww.jewishcarrollcounty.com%2ftemplates%2farticlecco_cdo%2faid%2f4867926%2fjewish%2fYizkor-Booklet.htm%23utm_medium%3dpage_tools%26utm_content%3ddesktop%26utm_source%3dpinterest&amp;description=Yizkor+Booklet+-+Chabad+Jewish+Center+Of+Carroll+County">
				<i class="fa fa-pinterest"></i>
			</a>
<a class="page-tools__tool" onclick="showEmailLayer(this);">
<i class="fa fa-envelope"></i>
</a>
</div>
<div class="page-tools__section page-tools__section--other js-page-tool-other">
<div class="page-tools__tool popover-parent d-lg-block">
<div class="popover popover--right align_left nowrap">
<div class="popover__content">
<label class="bold bottom_margin block">
Print Options:
</label>
<form class="vcenter" name="print-form" onsubmit="coPrint(event, 4867875);return false;">
<div>
<label><input type="checkbox" name="print-green"><span title="Save paper and ink">Print without images <i class="fa fa-leaf text-green"></i></span></label>
</div>
<br/>
<div class="center">
<button class="co-button page-tools__print-button">Print</button>
</div>
</form>
</div>
</div>
<i class="fa fa-print"></i>
</div>
</div>
</div>
<div class="js-fab-wrapper fab-wrapper">
<div class="fab">
<i class="fab-icon"></i>
</div>
</div>
</aside>
<!-- END CACHE -->
	</div>

	</div>

	<div id="BodyContainer">
		<div class="g960 footer">
			<div class="poweredby large_bottom_margin">
				


	<div class="footer3"><b>Sykesville MD 21784</b></div>
	<img src="https://w2.chabad.org/images/global/spacer.gif" width="1" height="6" border="0" /><br />




Powered by <a href="https://www.chabad.org/" target="_new" class="">Chabad.org</a> &copy; 1993-2026 <a href="/4026210" target="_blank" class="privacy-link">Privacy Policy</a>




			</div>
		</div>
	</div>
	
	

	
<script type="text/javascript" src="https://w2.chabad.org/scripts/js/os/jquery-latest.min.js?v=0293E3EC"></script>
<script type="text/javascript" src="https://w2.chabad.org/scripts/js/os/jquery/jquery.inputmask.min.js?v=BF33D3B4"></script>
<script type="text/javascript" src="https://w2.chabad.org/scripts/js/co/dist/CoLib.js?v=F809B22F"></script>
<script type="text/javascript" src="https://w2.chabad.org/scripts/js/WebComponents/bundles/magen-cdo-global.js?v=95D39855"></script>
<script type="text/javascript" src="https://w2.chabad.org/scripts/js/custom/multimedia/infolayer.js?v=ED1B8531"></script>
<script type="text/javascript" src="https://w2.chabad.org/scripts/js/templates/forms/userform.js?v=7F5B58AF"></script>
<script type="text/javascript" src="https://w2.chabad.org/scripts/js/custom/commentsloader.js?v=AD6AAB79"></script>
<script type="text/javascript" src="https://w2.chabad.org/scripts/js/custom/minisites.js?v=F38E4DA5"></script>
<script type="text/javascript" src="https://w2.chabad.org/scripts/js/custom/subscribeprompt.js?v=86D84DC2"></script>
<script type="text/javascript" src="https://w2.chabad.org/scripts/js/templates/FormDecoder.js?v=83AF6F1A"></script>
<script type="text/javascript" src="https://w2.chabad.org/scripts/js/modules/pagetools.js?v=930B07AB"></script>
<script type="text/javascript" src="https://w2.chabad.org/scripts/js/custom/deprecated.js?v=D506A83E"></script>
<script type="text/javascript" src="https://w2.chabad.org/scripts/js/OverrideJSDocumentWrite.js?v=9A0227AA"></script><script>$j = $j.fn ? $j : jQuery;$j(()=>{$q.forEach(f=>{try{f.call(window);}catch(ex){console.error(ex);}});})</script>
	

<script  language="javascript" type="text/javascript"> Co.Settings      = {CacheClassName:'js-cache-default',MosadName:'Chabad Jewish Center Of Carroll County'}; Co.ArticleId     = '4867926';Co.SectionId     = 5221241;Co.PartnerSiteId = 0;Co.SiteId        = 9530;Co.IsMobilePage  = false;Co.IsResponsive  = false;Co.DbDomain      = 'JewishCarrollCounty.com';Co.LanguageCode  = '';Co.LoginStatus   = 'None';</script>
	
	

</body>
</html>