{"id":1206,"date":"2022-02-04T09:47:14","date_gmt":"2022-02-04T14:47:14","guid":{"rendered":"https:\/\/yfc.ca\/northumberland\/?page_id=1206"},"modified":"2026-01-27T19:23:17","modified_gmt":"2026-01-28T00:23:17","slug":"youth-with-a-purpose-registration","status":"publish","type":"page","link":"https:\/\/yfc.ca\/northumberland\/youth-with-a-purpose-registration\/","title":{"rendered":"Youth with a Purpose Registration"},"content":{"rendered":"<section class=\"y-single-image narrow  guten-block\">\r\n\t\r\n\t\t\t<div class=\"grid-narrow\">\r\n\t\t\t<img decoding=\"async\" class=\"narrow\" src=\"https:\/\/yfc.ca\/northumberland\/wp-content\/uploads\/sites\/32\/2021\/09\/NYFC-YouthwithaPurpose-Logo-scaled.jpg\" alt=\"Youth with a purpose logo\" \/>\r\n\t\t<\/div>\r\n\t<\/section>\r\n\n\n<section class=\"y-hl  guten-block\">\r\n\t<div class=\"grid-narrow\">\r\n\t\t<hr class=\"black\" \/>\r\n\t<\/div>\r\n<\/section>\r\n\n\n<section class=\"y-columned-content white one center  guten-block\" >\r\n\t<div class=\"grid-narrow\">\r\n\t\t\t\t<div class=\"y-columned-content--inner\">\r\n\t\t\t\t\t\t\t<div class=\"y-columned-content--column y-color-responsive-text\"><p style=\"text-align: left;\">Youth with a Purpose runs on Monday evenings. Registration is required (below).<\/p>\n<p style=\"text-align: left;\">For more information, please contact Connie at <a href=\"mailto:connie@nyfc.org\">connie@nyfc.org<\/a>.<\/p>\n<p>&nbsp;<\/p>\n<p style=\"text-align: center;\"><a class=\"button secondary\" href=\"#registration\">Go to the registration form<\/a><\/p>\n<p style=\"text-align: center;\"><a class=\"button primary\" href=\"https:\/\/yfc.ca\/northumberland\/program\/purpose\/\">Back to the Youth With a Purpose page<\/a><\/p>\n<\/div>\r\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\r\n\t<\/div>\r\n<\/section>\r\n\n\n\n<a name=\"registration\"><\/a>\n\n\n\t<section class=\"y-gravity-form white  guten-block\" >\r\n\t\t<div class=\"grid-narrow\">\r\n\t\t\t\t\t\t\t<h3 class=\"y-accordion--title y-color-responsive-text\">Youth with a Purpose Registration 2026<\/h3>\r\n\t\t\t\t\t\t<div class=\"y-gravity-form--inner\">\r\n\t\t\t\t<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar 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d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_18' style='display:none'><div id='gf_18' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_18' id='gform_18'  action='\/northumberland\/wp-json\/wp\/v2\/pages\/1206#gf_18' data-formid='18' novalidate><div class='gf_invisible ginput_recaptchav3' data-sitekey='6Lfq1YsaAAAAAIlCN1-uzuUjef83MGbopf9xeWCd' data-tabindex='0'><input id=\"input_d2c83a2b70b2758c0e33dce14d878ec9\" class=\"gfield_recaptcha_response\" type=\"hidden\" name=\"input_d2c83a2b70b2758c0e33dce14d878ec9\" value=\"\"\/><\/div>\n                        <div class='gform-body gform_body'><ul id='gform_fields_18' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_18_55\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_18_55'>Program Season<\/label><div class='ginput_container ginput_container_select'><select name='input_55' id='input_18_55' class='large gfield_select'     aria-invalid=\"false\" ><option value='Feb 2026' >Feb 2026<\/option><\/select><\/div><\/li><li id=\"field_18_64\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_18_64'>Program &#8211; for iATS Comments<\/label><div class='ginput_container ginput_container_select'><select name='input_64' id='input_18_64' class='large gfield_select'     aria-invalid=\"false\" ><option value='Youth with a Purpose Feb 2026' >Youth with a Purpose Feb 2026<\/option><\/select><\/div><\/li><li id=\"field_18_32\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_18_32'>How many youth are you registering? (ages 10-14)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_32' id='input_18_32' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='One' >One<\/option><option value='Two' >Two<\/option><option value='Three' >Three<\/option><\/select><\/div><\/li><li id=\"field_18_28\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Youth #1 Info<\/h2><\/li><li id=\"field_18_7\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_18_7'>\n                            \n                            <span id='input_18_7_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_7.3' id='input_18_7_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_18_7_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_18_7_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_7.6' id='input_18_7_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_18_7_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_18_41\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_18_41'>Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_41' id='input_18_41' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_18_41_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_18_41_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_18_41' class='gform_hidden' value='https:\/\/yfc.ca\/northumberland\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_18_10\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_18_10'>Gender<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_10' id='input_18_10' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_18_20\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_18_20'>Allergies or Medical Conditions<\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_18_20' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_18_31\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_18_31'>Other helpful information which may help your child thrive in the program<\/label><div class='ginput_container ginput_container_text'><input name='input_31' id='input_18_31' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_18_33\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Youth #2 Info<\/h2><\/li><li id=\"field_18_34\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_18_34'>\n                            \n                            <span id='input_18_34_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_34.3' id='input_18_34_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_18_34_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_18_34_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_34.6' id='input_18_34_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_18_34_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_18_9\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_18_9'>Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_9' id='input_18_9' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_18_9_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_18_9_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_18_9' class='gform_hidden' value='https:\/\/yfc.ca\/northumberland\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_18_44\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_18_44'>Gender<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_44' id='input_18_44' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_18_49\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_18_49'>Allergies or Medical Conditions<\/label><div class='ginput_container ginput_container_text'><input name='input_49' id='input_18_49' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_18_50\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_18_50'>Other helpful information that may help your child thrive in the program<\/label><div class='ginput_container ginput_container_text'><input name='input_50' id='input_18_50' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_18_35\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Youth #3 Info<\/h2><\/li><li id=\"field_18_38\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_18_38'>\n                            \n                            <span id='input_18_38_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_38.3' id='input_18_38_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_18_38_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_18_38_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_38.6' id='input_18_38_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_18_38_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_18_39\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_18_39'>Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_39' id='input_18_39' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_18_39_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_18_39_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_18_39' class='gform_hidden' value='https:\/\/yfc.ca\/northumberland\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_18_43\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_18_43'>Gender<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_43' id='input_18_43' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_18_48\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_18_48'>Allergies or Medical Conditions<\/label><div class='ginput_container ginput_container_text'><input name='input_48' id='input_18_48' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_18_51\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_18_51'>Other helpful information that may help your child thrive in the program<\/label><div class='ginput_container ginput_container_text'><input name='input_51' id='input_18_51' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_18_11\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Home Address<\/h2><\/li><li id=\"field_18_22\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_18_22' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_18_22_1_container' >\n                                        <input type='text' name='input_22.1' id='input_18_22_1' value=''    aria-required='true'    \/>\n                                        <label for='input_18_22_1' id='input_18_22_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_18_22_2_container' >\n                                        <input type='text' name='input_22.2' id='input_18_22_2' value=''     aria-required='false'   \/>\n                                        <label for='input_18_22_2' id='input_18_22_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_18_22_3_container' >\n                                    <input type='text' name='input_22.3' id='input_18_22_3' value=''    aria-required='true'    \/>\n                                    <label for='input_18_22_3' id='input_18_22_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_18_22_4_container' >\n                                        <select name='input_22.4' id='input_18_22_4'     aria-required='true'    ><option value='' ><\/option><option value='Alberta' >Alberta<\/option><option value='British Columbia' >British Columbia<\/option><option value='Manitoba' >Manitoba<\/option><option value='New Brunswick' >New Brunswick<\/option><option value='Newfoundland and Labrador' >Newfoundland and Labrador<\/option><option value='Northwest Territories' >Northwest Territories<\/option><option value='Nova Scotia' >Nova Scotia<\/option><option value='Nunavut' >Nunavut<\/option><option value='Ontario' selected='selected'>Ontario<\/option><option value='Prince Edward Island' >Prince Edward Island<\/option><option value='Quebec' >Quebec<\/option><option value='Saskatchewan' >Saskatchewan<\/option><option value='Yukon' >Yukon<\/option><\/select>\n                                        <label for='input_18_22_4' id='input_18_22_4_label' class='gform-field-label gform-field-label--type-sub '>Province<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_18_22_5_container' >\n                                    <input type='text' name='input_22.5' id='input_18_22_5' value=''    aria-required='true'    \/>\n                                    <label for='input_18_22_5' id='input_18_22_5_label' class='gform-field-label gform-field-label--type-sub '>Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_22.6' id='input_18_22_6' value='Canada' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_18_21\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Parent\/Guardian Info<\/h2><\/li><li id=\"field_18_12\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >1st Parent\/Guardian Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_18_12'>\n                            \n                            <span id='input_18_12_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_12.3' id='input_18_12_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_18_12_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_18_12_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_12.6' id='input_18_12_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_18_12_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_18_13\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_18_13'>1st Parent\/Guardian Cell Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_13' id='input_18_13' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_18_23\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >1st Parent\/Guardian Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_18_23_container'>\n                                <span id='input_18_23_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_23' id='input_18_23' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_18_23' class='gform-field-label gform-field-label--type-sub '>Enter Email<\/label>\n                                <\/span>\n                                <span id='input_18_23_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_23_2' id='input_18_23_2' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_18_23_2' class='gform-field-label gform-field-label--type-sub '>Confirm Email<\/label>\n                                <\/span>\n                                <div class='gf_clear gf_clear_complex'><\/div>\n                            <\/div><\/li><li id=\"field_18_24\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >2nd Parent\/Guardian Name<\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_18_24'>\n                            \n                            <span id='input_18_24_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_24.3' id='input_18_24_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_18_24_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_18_24_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_24.6' id='input_18_24_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_18_24_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_18_25\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_18_25'>2nd Parent\/Guardian Cell Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_25' id='input_18_25' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_18_26\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >2nd Parent\/Guardian Email<\/label><div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_18_26_container'>\n                                <span id='input_18_26_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_26' id='input_18_26' value=''     aria-invalid=\"false\"  \/>\n                                    <label for='input_18_26' class='gform-field-label gform-field-label--type-sub '>Enter Email<\/label>\n                                <\/span>\n                                <span id='input_18_26_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_26_2' id='input_18_26_2' value=''     aria-invalid=\"false\"  \/>\n                                    <label for='input_18_26_2' class='gform-field-label gform-field-label--type-sub '>Confirm Email<\/label>\n                                <\/span>\n                                <div class='gf_clear gf_clear_complex'><\/div>\n                            <\/div><\/li><li id=\"field_18_14\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Consents<\/h2><\/li><li id=\"field_18_15\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >MEDICAL \/ PERSONAL HARM<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_consent'><input name='input_15.1' id='input_18_15_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_18_15\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_18_15_1' >Yes<\/label><input type='hidden' name='input_15.2' value='Yes' class='gform_hidden' \/><input type='hidden' name='input_15.3' value='61' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_18_15' tabindex='0'>I hereby release Northumberland Youth Unlimited from responsibility and liability for any harm that may occur to the youth in my care noted above, as a result of their wilful participation in the program\/activity described above. I understand that reasonable precautions for the health and safety of participants will be taken. Furthermore, I give permission for the person(s) in charge to seek medical assistance for the youth in my care noted above, in the event of accident or injury, and acknowledge that I must assume total responsibility for any and all medical assistance related costs. Every attempt will be made to contact parents or guardians before such action.<\/div><\/li><li id=\"field_18_17\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >AGE 10+ PERMISSION TO SIGN IN\/OUT (optional)<\/label><div class='ginput_container ginput_container_consent'><input name='input_17.1' id='input_18_17_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_18_17\"  aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_18_17_1' >Yes<\/label><input type='hidden' name='input_17.2' value='Yes' class='gform_hidden' \/><input type='hidden' name='input_17.3' value='61' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_18_17' tabindex='0'>I give permission to the youth in my care noted above (age 10+) to sign themselves in and\/or out without a parent present. In doing so, I release Northumberland Youth Unlimited of any responsibility after they sign out and leave the premises.<\/div><\/li><li id=\"field_18_54\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >FAITH DISCLOSURE<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_consent'><input name='input_54.1' id='input_18_54_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_18_54\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_18_54_1' >Yes<\/label><input type='hidden' name='input_54.2' value='Yes' class='gform_hidden' \/><input type='hidden' name='input_54.3' value='61' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_18_54' tabindex='0'>I understand that Northumberland Youth Unlimited is a faith-based charitable organization that is operated by Christian values. I understand that Northumberland Youth Unlimited is inclusive to all program participants regardless of their personal religious belief, race, sexuality, gender, or socio-economic status. I understand that the staff and volunteers of Northumberland Youth Unlimited, with the utmost dignity and respect, may engage in conversations and\/or lessons regarding topics of faith with the youth in my care noted above, during the course of their participation with Northumberland Youth Unlimited.<\/div><\/li><li id=\"field_18_53\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >PHOTO \/ VIDEO (optional)<\/label><div class='ginput_container ginput_container_consent'><input name='input_53.1' id='input_18_53_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_18_53\"  aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_18_53_1' >Yes<\/label><input type='hidden' name='input_53.2' value='Yes' class='gform_hidden' \/><input type='hidden' name='input_53.3' value='61' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_18_53' tabindex='0'>I do authorize Northumberland Youth Unlimited to take, use and own, in perpetuity; photo\/video\/audio recordings of the youth in my care noted above, understanding that these may be used for public promotional purposes. NOTE: Northumberland Youth Unlimited does not sell or give away any recorded materials or mailing list information.<\/div><\/li><li id=\"field_18_27\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >PARTICIPATION<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_consent'><input name='input_27.1' id='input_18_27_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_18_27\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_18_27_1' >Yes<\/label><input type='hidden' name='input_27.2' value='Yes' class='gform_hidden' \/><input type='hidden' name='input_27.3' value='61' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_18_27' tabindex='0'>I understand that the program\/activity described above is a program of Northumberland Youth Unlimited and all consents on this page also apply to this program\/activity. I have read, understood and hereby give permission for the youth in my care noted above, to attend and participate fully in the program\/activity described above by Northumberland Youth Unlimited and agree to these waivers and conditions.<\/div><\/li><li id=\"field_18_19\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_18_19'>Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><input type='hidden' value='' name='input_19' id='input_18_19_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_18_19_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><canvas id='input_18_19' width='300' height='180' style='border-style: Dashed; border-width: 2px; border-color: #DDDDDD; background-color:#FFFFFF; cursor: url(https:\/\/yfc.ca\/northumberland\/wp-content\/plugins\/gravityformssignature\/assets\/img\/pen.cur), pointer;'><\/canvas><\/div><div id='input_18_19_toolbar' style='margin:5px 0;position:relative;height:20px;width:300px;max-width:100%;'><img id = 'input_18_19_resetbutton' src='data:image\/png;base64,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' style='cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent' alt='Clear Signature' \/ ><\/div><input type='hidden' id='input_18_19_data' name='input_18_19_data' value=''><\/div><\/li><li id=\"field_18_56\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Fees<\/h2><\/li><li id=\"field_18_57\" class=\"gfield gfield--type-product gfield--input-type-singleproduct gfield--width-full gfield_price gfield_price_18_57 gfield_product_18_57 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' for='input_18_57_1'>YWP Registration Fee #1<\/label><div class='ginput_container ginput_container_singleproduct'>\n\t\t\t\t\t<input type='hidden' name='input_57.1' value='YWP Registration Fee #1' class='gform_hidden' \/>\n\t\t\t\t\t\n\t\t\t\t\t\t<label for='ginput_base_price_18_57' class='gform-field-label gform-field-label--type-sub-large ginput_product_price_label'>Price:<\/label>\n\t\t\t\t\t\t<input type='text' readonly class='ginput_product_price gform-text-input-reset' name='input_57.2' id='ginput_base_price_18_57' value='$ 25.00 CAD' aria-label='YWP Registration Fee #1 Price'  \/>\n\t\t\t\t\t\n\t\t\t\t\t<input type='hidden' name='input_57.3' value='1' class='ginput_quantity_18_57 gform_hidden' \/>\n\t\t\t\t<\/div><\/li><li id=\"field_18_58\" class=\"gfield gfield--type-product gfield--input-type-singleproduct gfield--width-full gfield_price gfield_price_18_58 gfield_product_18_58 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' for='input_18_58_1'>YWP Registration Fee #2<\/label><div class='ginput_container ginput_container_singleproduct'>\n\t\t\t\t\t<input type='hidden' name='input_58.1' value='YWP Registration Fee #2' class='gform_hidden' \/>\n\t\t\t\t\t\n\t\t\t\t\t\t<label for='ginput_base_price_18_58' class='gform-field-label gform-field-label--type-sub-large ginput_product_price_label'>Price:<\/label>\n\t\t\t\t\t\t<input type='text' readonly class='ginput_product_price gform-text-input-reset' name='input_58.2' id='ginput_base_price_18_58' value='$ 25.00 CAD' aria-label='YWP Registration Fee #2 Price'  \/>\n\t\t\t\t\t\n\t\t\t\t\t<input type='hidden' name='input_58.3' value='1' class='ginput_quantity_18_58 gform_hidden' \/>\n\t\t\t\t<\/div><\/li><li id=\"field_18_59\" class=\"gfield gfield--type-product gfield--input-type-singleproduct gfield--width-full gfield_price gfield_price_18_59 gfield_product_18_59 field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' for='input_18_59_1'>YWP Registration Fee #3<\/label><div class='ginput_container ginput_container_singleproduct'>\n\t\t\t\t\t<input type='hidden' name='input_59.1' value='YWP Registration Fee #3' class='gform_hidden' \/>\n\t\t\t\t\t\n\t\t\t\t\t\t<label for='ginput_base_price_18_59' class='gform-field-label gform-field-label--type-sub-large ginput_product_price_label'>Price:<\/label>\n\t\t\t\t\t\t<input type='text' readonly class='ginput_product_price gform-text-input-reset' name='input_59.2' id='ginput_base_price_18_59' value='$ 25.00 CAD' aria-label='YWP Registration Fee #3 Price'  \/>\n\t\t\t\t\t\n\t\t\t\t\t<input type='hidden' name='input_59.3' value='1' class='ginput_quantity_18_59 gform_hidden' \/>\n\t\t\t\t<\/div><\/li><li id=\"field_18_61\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Payment Details<\/h2><\/li><li id=\"field_18_62\" class=\"gfield gfield--type-creditcard gfield--input-type-creditcard gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' for='input_18_62_1'>Credit Card<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container_creditcard gform-grid-row' id='input_18_62'><span class='ginput_full gform-grid-col' id='input_18_62_1_container' >\n                                    <div class='gform_card_icon_container'><div class='gform_card_icon gform_card_icon_mastercard' >MasterCard<\/div><div class='gform_card_icon gform_card_icon_visa' >Visa<\/div><span class='screen-reader-text' id='field_18_62_supported_creditcards'>Supported Credit Cards: MasterCard, Visa<\/span><\/div>\n                                    <input type='text' name='input_62.1' id='input_18_62_1' value=''   onchange='gformMatchCard(\"input_18_62_1\");' onkeyup='gformMatchCard(\"input_18_62_1\");' autocomplete='off' pattern='[0-9]*' title='Only digits are allowed'  aria-required='true'  \/>\n                                    <label for='input_18_62_1' id='input_18_62_1_label' class='gform-field-label gform-field-label--type-sub '>Card Number<\/label>\n                                 <\/span><span class='ginput_full ginput_cardextras gform-grid-col gform-grid-row' id='input_18_62_2_container'>\n                                            <span class='ginput_cardinfo_left' id='input_18_62_2_cardinfo_left'>\n                                                <span class='ginput_card_expiration_container ginput_card_field'>\n                                                    \n                                                       <select name='input_62.2[]' id='input_18_62_2_month'   class='ginput_card_expiration ginput_card_expiration_month' aria-required='true'  >\n                                                           <option value=''>Month<\/option><option value='1' >01<\/option><option value='2' >02<\/option><option value='3' >03<\/option><option value='4' >04<\/option><option value='5' >05<\/option><option value='6' >06<\/option><option value='7' >07<\/option><option value='8' >08<\/option><option value='9' >09<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option>\n                                                       <\/select>\n                                                       \n                                                   \n                                                   \n                                                       <select name='input_62.2[]' id='input_18_62_2_year'   class='ginput_card_expiration ginput_card_expiration_year' aria-required='true'  >\n                                                           <option value=''>Year<\/option><option value='2026' >2026<\/option><option value='2027' >2027<\/option><option value='2028' >2028<\/option><option value='2029' >2029<\/option><option value='2030' >2030<\/option><option value='2031' >2031<\/option><option value='2032' >2032<\/option><option value='2033' >2033<\/option><option value='2034' >2034<\/option><option value='2035' >2035<\/option><option value='2036' >2036<\/option><option value='2037' >2037<\/option><option value='2038' >2038<\/option><option value='2039' >2039<\/option><option value='2040' >2040<\/option><option value='2041' >2041<\/option><option value='2042' >2042<\/option><option value='2043' >2043<\/option><option value='2044' >2044<\/option><option value='2045' >2045<\/option>\n                                                       <\/select>\n                                                       \n                                                       \n                                                <\/span>\n                                                 <label for='input_18_62_2_month' class='gform-field-label gform-field-label--type-sub '>Expiration Date<\/label>\n                                            <\/span><span class='ginput_cardinfo_right gform-grid-col' id='input_18_62_2_cardinfo_right'>\n                                                <input type='text' name='input_62.3' id='input_18_62_3'   class='ginput_card_security_code' value='' autocomplete='off' pattern='[0-9]*' title='Only digits are allowed'  aria-required='true'  \/>\n                                                <span class='ginput_card_security_code_icon'>&nbsp;<\/span>\n                                                <label for='input_18_62_3' class='gform-field-label gform-field-label--type-sub '>Security Code<\/label>\n                                             <\/span>\n                                        <\/span><span class='ginput_full gform-grid-col' id='input_18_62_5_container'>\n                                            <input type='text' name='input_62.5' id='input_18_62_5' value=''    aria-required='false'  \/>\n                                            <label for='input_18_62_5' id='input_18_62_5_label' class='gform-field-label gform-field-label--type-sub '>Cardholder Name<\/label>\n                                        <\/span> <\/div><\/li><li id=\"field_18_63\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_18_60\" class=\"gfield gfield--type-total gfield--input-type-total gfield--width-full gfield_price gfield_price_18_ gfield_total gfield_total_18_ field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  aria-atomic=\"true\" aria-live=\"polite\" ><label class='gfield_label gform-field-label' for='input_18_60'>Total<\/label><div class='ginput_container ginput_container_total'>\n\t\t\t\t\t\t\t<span class='ginput_total ginput_total_18'>$ 0.00 CAD<\/span>\n\t\t\t\t\t\t\t<input type='hidden' name='input_60' id='input_18_60' class='gform_hidden'\/>\n\t\t\t\t\t\t<\/div><\/li><\/ul><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_18' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit'  \/> <input type='hidden' name='gform_ajax' value='form_id=18&amp;title=&amp;description=&amp;tabindex=0&amp;theme=legacy&amp;styles=[]&amp;hash=03ae814454820fd5f8400758e55c6daf' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_18' value='iframe' \/>\n     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