{"id":1977,"date":"2023-05-20T14:51:15","date_gmt":"2023-05-20T18:51:15","guid":{"rendered":"https:\/\/yfc.ca\/northumberland\/?page_id=1977"},"modified":"2024-06-18T10:17:12","modified_gmt":"2024-06-18T14:17:12","slug":"beacon-camping","status":"publish","type":"page","link":"https:\/\/yfc.ca\/northumberland\/beacon-camping\/","title":{"rendered":"Beacon Youth Centre Camping Trip"},"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\/2023\/05\/NYFC-Beacon-Logo-NewBlue.png\" alt=\"\" \/>\r\n\t\t<\/div>\r\n\t<\/section>\r\n\n\n<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\/2024\/06\/2024-Beacon-Camping-Trip-graphic.png\" alt=\"\" \/>\r\n\t\t<\/div>\r\n\t<\/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><strong>Come away with us for a few days of fun and fellowship as we celebrate a great year together at the Beacon!<\/strong> We&#8217;re going to have a blast in the water, playing games, hanging out together and more! Fun times planned around the campfire including guest speakers and musical performances. Bible discovery activities each day, great conversations and memories to be made. All food will be provided as well as any camping gear you need, but feel welcome to bring your own gear. We look forward to seeing you there!<\/p>\n<p><strong>Please register below.<\/strong> We are committed to ensuring that no youth will miss out due to finances, so please contact our Youth Unlimited office at 905-373-4707 or info@nyfc.org to apply for a subsidy (we do not require income testing or request personal financial information).<\/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\t<section class=\"y-gravity-form grey  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\">Beacon Camping Trip Registration<\/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 gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var 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_30' style='display:none'><div id='gf_30' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_30' id='gform_30'  action='\/northumberland\/wp-json\/wp\/v2\/pages\/1977#gf_30' data-formid='30' novalidate><div class='gf_invisible ginput_recaptchav3' data-sitekey='6Lfq1YsaAAAAAIlCN1-uzuUjef83MGbopf9xeWCd' data-tabindex='0'><input id=\"input_20e6ca9b186b110388f16192150352d6\" class=\"gfield_recaptcha_response\" type=\"hidden\" name=\"input_20e6ca9b186b110388f16192150352d6\" value=\"\"\/><\/div>\n                        <div class='gform-body gform_body'><ul id='gform_fields_30' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_30_83\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >The Beacon Youth Centre, a program of Northumberland Youth Unlimited, is holding a camping trip from July 26-28, 2024 at 419 Percy Boom Rd. Campbellford, ON. <\/li><li id=\"field_30_84\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Drop off will be at 2:00pm on Fri. July 26 and pick up will be 2:00pm on Sun. July 26.<\/li><li id=\"field_30_85\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Other instructions including what to bring, itinerary, emergency contact, etc&#8230; will follow closer to the date.<\/li><li id=\"field_30_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 Info<\/h2><\/li><li id=\"field_30_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_30_7'>\n                            \n                            <span id='input_30_7_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_7.3' id='input_30_7_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_30_7_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_30_7_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_7.6' id='input_30_7_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_30_7_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_30_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_30_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_30_41' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_30_41_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_30_41_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_30_41' class='gform_hidden' value='https:\/\/yfc.ca\/northumberland\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_30_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_30_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_30_10' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_30_80\" 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_30_80'>Health Card # (optional)<\/label><div class='ginput_container ginput_container_text'><input name='input_80' id='input_30_80' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_30_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_30_20'>Allergies or Medical Conditions<\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_30_20' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_30_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_30_31'>Other helpful information that may help your child thrive in this activity<\/label><div class='ginput_container ginput_container_text'><input name='input_31' id='input_30_31' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_30_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_30_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_30_22' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_30_22_1_container' >\n                                        <input type='text' name='input_22.1' id='input_30_22_1' value=''    aria-required='true'    \/>\n                                        <label for='input_30_22_1' id='input_30_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_30_22_2_container' >\n                                        <input type='text' name='input_22.2' id='input_30_22_2' value=''     aria-required='false'   \/>\n                                        <label for='input_30_22_2' id='input_30_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_30_22_3_container' >\n                                    <input type='text' name='input_22.3' id='input_30_22_3' value=''    aria-required='true'    \/>\n                                    <label for='input_30_22_3' id='input_30_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_30_22_4_container' >\n                                        <select name='input_22.4' id='input_30_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_30_22_4' id='input_30_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_30_22_5_container' >\n                                    <input type='text' name='input_22.5' id='input_30_22_5' value=''    aria-required='true'    \/>\n                                    <label for='input_30_22_5' id='input_30_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_30_22_6' value='Canada' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_30_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_30_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_30_12'>\n                            \n                            <span id='input_30_12_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_12.3' id='input_30_12_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_30_12_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_30_12_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_12.6' id='input_30_12_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_30_12_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_30_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_30_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_30_13' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_30_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' >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_30_23_container'>\n                                <span id='input_30_23_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_23' id='input_30_23' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_30_23' class='gform-field-label gform-field-label--type-sub '>Enter Email<\/label>\n                                <\/span>\n                                <span id='input_30_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_30_23_2' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_30_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_30_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_30_24'>\n                            \n                            <span id='input_30_24_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_24.3' id='input_30_24_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_30_24_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_30_24_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_24.6' id='input_30_24_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_30_24_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_30_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_30_25'>2nd Parent\/Guardian Cell Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_25' id='input_30_25' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_30_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' >2nd Parent\/Guardian Email<\/label><div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_30_26_container'>\n                                <span id='input_30_26_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_26' id='input_30_26' value=''     aria-invalid=\"false\"  \/>\n                                    <label for='input_30_26' class='gform-field-label gform-field-label--type-sub '>Enter Email<\/label>\n                                <\/span>\n                                <span id='input_30_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_30_26_2' value=''     aria-invalid=\"false\"  \/>\n                                    <label for='input_30_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_30_82\" 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' >Alternative Emergency Contact<\/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_30_82'>\n                            \n                            <span id='input_30_82_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_82.3' id='input_30_82_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_30_82_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_30_82_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_82.6' id='input_30_82_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_30_82_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_30_81\" 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_30_81'>Alternative Emergency Contact Cell Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_81' id='input_30_81' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_30_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_30_86\" 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_86.1' id='input_30_86_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_30_86\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_30_86_1' >Yes<\/label><input type='hidden' name='input_86.2' value='Yes' class='gform_hidden' \/><input type='hidden' name='input_86.3' value='60' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_30_86' tabindex='0'>I hereby release Northumberland Youth Unlimited and its subsidiary program the Beacon Youth Centre, 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 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_30_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' >TRANSPORTATION<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_30_15_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_30_15\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_30_15_1' >Yes<\/label><input type='hidden' name='input_15.2' value='Yes' class='gform_hidden' \/><input type='hidden' name='input_15.3' value='60' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_30_15' tabindex='0'>I give permission for the youth in my care noted above, to travel in a vehicle owned by Northumberland Youth Unlimited or its subsidiary program the Beacon Youth Centre, or by its staff or volunteers, from July 26-28, 2024 for the purposes of travelling to the campsite from Brighton, and back again. I understand that drivers and their vehicles are licensed and insured according to local, provincial and federal laws, insurance policies and NYU\u2019s Policies &#038; Procedures. Furthermore, I do not hold Northumberland Youth Unlimited and its subsidiary program the Beacon Youth Centre, responsible for any harm that may occur to the youth in my care noted above, as a result of his\/her wilful participation in the transportation.<\/div><\/li><li id=\"field_30_78\" 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_78.1' id='input_30_78_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_30_78\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_30_78_1' >Yes<\/label><input type='hidden' name='input_78.2' value='Yes' class='gform_hidden' \/><input type='hidden' name='input_78.3' value='60' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_30_78' tabindex='0'>I understand that Northumberland Youth Unlimited and its subsidiary program the Beacon Youth Centre, is a faith-based charitable organization that is governed and operated by Christian values, principles and beliefs. I understand that Northumberland Youth Unlimited and its subsidiary program the Beacon Youth Centre, is inclusive to all 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 and its subsidiary program the Beacon Youth Centre, with the utmost dignity and respect, may engage in discussions, conversations and\/or lessons regarding topics of faith with my child during the course of their participation with Northumberland Youth Unlimited and its subsidiary program the Beacon Youth Centre.<\/div><\/li><li id=\"field_30_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_30_17_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_30_17\"  aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_30_17_1' >Yes<\/label><input type='hidden' name='input_17.2' value='Yes' class='gform_hidden' \/><input type='hidden' name='input_17.3' value='60' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_30_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 and its subsidiary program the Beacon Youth Centre, of any responsibility after they sign out and leave the premises.<\/div><\/li><li id=\"field_30_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_30_53_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_30_53\"  aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_30_53_1' >Yes<\/label><input type='hidden' name='input_53.2' value='Yes' class='gform_hidden' \/><input type='hidden' name='input_53.3' value='60' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_30_53' tabindex='0'>I do authorize Northumberland Youth Unlimited and its subsidiary program the Beacon Youth Centre, 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\u00a0purposes. NOTE: Northumberland Youth Unlimited nor its subsidiary program the Beacon Youth Centre, does not sell or give away any recorded materials or mailing list information.<\/div><\/li><li id=\"field_30_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_30_27_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_30_27\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_30_27_1' >Yes<\/label><input type='hidden' name='input_27.2' value='Yes' class='gform_hidden' \/><input type='hidden' name='input_27.3' value='60' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_30_27' tabindex='0'>I have read, understood and hereby give permission for the youth in my care noted above, to attend and participate fully in the activity described above by Northumberland Youth Unlimited and its subsidiary program the Beacon Youth Centre, and agree to these waivers and conditions. I acknowledge that the youth in my care noted above, may be sent home if they are unable to follow the rules.<\/div><\/li><li id=\"field_30_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_30_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_30_19_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_30_19_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><canvas id='input_30_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_30_19_toolbar' style='margin:5px 0;position:relative;height:20px;width:300px;max-width:100%;'><img id = 'input_30_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_30_19_data' name='input_30_19_data' value=''><\/div><\/li><li id=\"field_30_55\" 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<\/h2><\/li><li id=\"field_30_79\" class=\"gfield gfield--type-product gfield--input-type-singleproduct gfield--width-full gfield_price gfield_price_30_79 gfield_product_30_79 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_30_79_1'>Product Name<\/label><div class='ginput_container ginput_container_singleproduct'>\n\t\t\t\t\t<input type='hidden' name='input_79.1' value='Product Name' class='gform_hidden' \/>\n\t\t\t\t\t\n\t\t\t\t\t\t<label for='ginput_base_price_30_79' 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_79.2' id='ginput_base_price_30_79' value='$ 40.00 CAD' aria-label='Product Name Price'  \/>\n\t\t\t\t\t\n\t\t\t\t\t<input type='hidden' name='input_79.3' value='1' class='ginput_quantity_30_79 gform_hidden' \/>\n\t\t\t\t<\/div><\/li><li id=\"field_30_60\" class=\"gfield gfield--type-total gfield--input-type-total gfield--width-full gfield_price gfield_price_30_ gfield_total gfield_total_30_ 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_30_60'>Total<\/label><div class='ginput_container ginput_container_total'>\n\t\t\t\t\t\t\t<span class='ginput_total ginput_total_30'>$ 0.00 CAD<\/span>\n\t\t\t\t\t\t\t<input type='hidden' name='input_60' id='input_30_60' class='gform_hidden'\/>\n\t\t\t\t\t\t<\/div><\/li><li id=\"field_30_77\" 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 Info<\/h2><\/li><li id=\"field_30_62\" 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_30_62'>Payment Method<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_62' id='input_30_62' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Credit Card' >Credit Card<\/option><option value='Direct Debit' >Direct Debit<\/option><option value='E-Transfer' >E-Transfer<\/option><\/select><\/div><\/li><li id=\"field_30_63\" 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_30_63_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_30_63'><span class='ginput_full gform-grid-col' id='input_30_63_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_30_63_supported_creditcards'>Supported Credit Cards: MasterCard, Visa<\/span><\/div>\n                                    <input type='text' name='input_63.1' id='input_30_63_1' value=''   onchange='gformMatchCard(\"input_30_63_1\");' onkeyup='gformMatchCard(\"input_30_63_1\");' autocomplete='off' pattern='[0-9]*' title='Only digits are allowed'  aria-required='true'  \/>\n                                    <label for='input_30_63_1' id='input_30_63_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_30_63_2_container'>\n                                            <span class='ginput_cardinfo_left' id='input_30_63_2_cardinfo_left'>\n                                                <span class='ginput_card_expiration_container ginput_card_field'>\n                                                    \n                                                       <select name='input_63.2[]' id='input_30_63_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_63.2[]' id='input_30_63_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_30_63_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_30_63_2_cardinfo_right'>\n                                                <input type='text' name='input_63.3' id='input_30_63_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_30_63_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_30_63_5_container'>\n                                            <input type='text' name='input_63.5' id='input_30_63_5' value=''    aria-required='false'  \/>\n                                            <label for='input_30_63_5' id='input_30_63_5_label' class='gform-field-label gform-field-label--type-sub '>Cardholder Name<\/label>\n                                        <\/span> <\/div><\/li><li id=\"field_30_65\" class=\"gfield gfield--type-ach gfield--input-type-ach 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 gfield_label_before_complex' for='input_30_65_1'>Direct Debit Information<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container_ach' id='input_30_65'><span class='ginput_full' id='input_30_65_4_container'>\r\n                                            <input type='text' name='input_65.4' id='input_30_65_4' value=''   \/>\r\n                                            <label for='input_30_65_4' id='input_30_65_4_label' >Account Holder Name<\/label>\r\n                                        <\/span><span class='ginput_left' id='input_30_65_1_container' >\r\n\t\t\t\t\t\t\t\t\t<input type='text' name='input_65.1' id='input_30_65_1' value=''     autocomplete='off' pattern='[0-9]*' title='Only digits are allowed' \/>\r\n\t\t\t\t\t\t\t\t\t<label for='input_30_65_1' id='input_30_65_1_label' >Account Number<\/label>\r\n\t\t\t\t\t\t\t\t <\/span><span class='ginput_right' id='input_30_65_3_container'>\r\n                                    <select name='input_65.3' id='input_30_65_3'   class='ginput_card_expiration'>\r\n\t\t\t\t\t\t\t\t\t\t<option value=''>Select<\/option><option value='S' >Savings<\/option><option value='C' >Checking<\/option>\r\n\t\t\t\t\t\t\t\t\t<\/select>\r\n                                    <label for='input_30_65_3' id='input_30_65_3_label' >Account Type<\/label>\r\n                                 <\/span><span class='ginput_left' id='input_30_65_2_container' >\r\n                                    <input type='text' name='input_65.2' id='input_30_65_2' value=''     autocomplete='off' pattern='[0-9]*' title='Only digits are allowed' \/>\r\n                                    <label for='input_30_65_2' id='input_30_65_2_label' >Institution\/Bank<\/label>\r\n                                 <\/span><span class='ginput_right' id='input_30_65_5_container' >\r\n\t\t\t\t\t\t\t\t\t<input type='text' name='input_65.5' id='input_30_65_5' value=''     autocomplete='off' pattern='[0-9]*' title='Only digits are allowed' \/>\r\n\t\t\t\t\t\t\t\t\t<label for='input_30_65_5' id='input_30_65_5_label' >Transit\/Branch<\/label>\r\n\t\t\t\t\t\t\t\t <\/span> <\/div><\/li><li id=\"field_30_66\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><img decoding=\"async\" src=\"https:\/\/yfc.ca\/northumberland\/wp-content\/uploads\/sites\/32\/2022\/03\/cheque_info.jpeg\" \/><\/li><li id=\"field_30_67\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Please send your e-transfer to info@nyfc.org ASAP and include a comment regarding &#8220;Beacon Camping Trip&#8221;. We use auto-deposit so please ensure your e-transfer is accurate. <\/li><li id=\"field_30_64\" 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' >Billing Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    <div id='input_30_64_copy_values_option_container' class='copy_values_option_container' >\n                                        <input type='checkbox' id='input_30_64_copy_values_activated' class='copy_values_activated' value='1' data-source_field_id='22' name='input_64_copy_values_activated'  \/>\n                                        <label for='input_30_64_copy_values_activated' id='input_30_64_copy_values_option_label' class='copy_values_option_label inline gform-field-label gform-field-label--type-inline'>Same as home address<\/label>\n                                    <\/div>\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_30_64' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_30_64_1_container' >\n                                        <input type='text' name='input_64.1' id='input_30_64_1' value=''    aria-required='true'    \/>\n                                        <label for='input_30_64_1' id='input_30_64_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_30_64_2_container' >\n                                        <input type='text' name='input_64.2' id='input_30_64_2' value=''     aria-required='false'   \/>\n                                        <label for='input_30_64_2' id='input_30_64_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_30_64_3_container' >\n                                    <input type='text' name='input_64.3' id='input_30_64_3' value=''    aria-required='true'    \/>\n                                    <label for='input_30_64_3' id='input_30_64_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_30_64_4_container' >\n                                        <select name='input_64.4' id='input_30_64_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_30_64_4' id='input_30_64_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_30_64_5_container' >\n                                    <input type='text' name='input_64.5' id='input_30_64_5' value=''    aria-required='true'    \/>\n                                    <label for='input_30_64_5' id='input_30_64_5_label' class='gform-field-label gform-field-label--type-sub '>Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_64.6' id='input_30_64_6' value='Canada' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><\/ul><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_30' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit'  \/> <input type='hidden' name='gform_ajax' value='form_id=30&amp;title=&amp;description=&amp;tabindex=0&amp;theme=legacy&amp;styles=[]&amp;hash=321bf94d6bb75abcc735a9cfe10c4b89' \/>\n            <input type='hidden' 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