var qsProxy = {};
function FrameBuilder(formId,appendTo,initialHeight,iframeCode,title,embedStyleJSON){this.formId=formId;this.initialHeight=initialHeight;this.iframeCode=iframeCode;this.frame=null;this.timeInterval=200;this.appendTo=appendTo||false;this.formSubmitted=0;this.frameMinWidth='100%';this.defaultHeight='';this.init=function(){this.embedURLHash=this.getMD5(window.location.href);if(embedStyleJSON&&(embedStyleJSON[this.embedURLHash]&&embedStyleJSON[this.embedURLHash]['inlineStyle']['embedWidth'])){this.frameMinWidth=embedStyleJSON[this.embedURLHash]['inlineStyle']['embedWidth']+'px';}
if(embedStyleJSON&&(embedStyleJSON[this.embedURLHash])){if(embedStyleJSON[this.embedURLHash]['inlineStyle']&&embedStyleJSON[this.embedURLHash]['inlineStyle']['embedHeight']){this.defaultHeight='data-frameHeight="'+embedStyleJSON[this.embedURLHash]['inlineStyle']['embedHeight']+'"';}}
this.createFrame();this.addFrameContent(this.iframeCode);};this.createFrame=function(){var tmp_is_ie=!!window.ActiveXObject;this.iframeDomId=document.getElementById(this.formId)?this.formId+'_'+new Date().getTime():this.formId;if(typeof $jot!=='undefined'){var iframe=document.getElementById("212695859147167");var parent=$jot(iframe).closest('.jt-feedback.u-responsive-lightbox');if(parent){this.iframeDomId='lightbox-'+this.iframeDomId;}}
var htmlCode="<"+"iframe title=\""+title.replace(/[\\"']/g,'\\$&').replace(/&amp;/g,'&')+"\" src=\"\" allowtransparency=\"true\" allow=\"geolocation; microphone; camera\" allowfullscreen=\"true\" name=\""+this.formId+"\" id=\""+this.iframeDomId+"\" style=\"width: 10px; min-width:"+this.frameMinWidth+"; display: block; overflow: hidden; height:"+this.initialHeight+"px; border: none;\" scrolling=\"no\""+this.defaultHeight+"></if"+"rame>";if(this.appendTo===false){document.write(htmlCode);}else{var tmp=document.createElement('div');tmp.innerHTML=htmlCode;var a=this.appendTo;document.getElementById(a).appendChild(tmp.firstChild);}
this.frame=document.getElementById(this.iframeDomId);if(tmp_is_ie===true){try{var iframe=this.frame;var doc=iframe.contentDocument?iframe.contentDocument:(iframe.contentWindow.document||iframe.document);doc.open();doc.write("");}
catch(err){this.frame.src="javascript:void((function(){document.open();document.domain=\'"+this.getBaseDomain()+"\';document.close();})())";}}
this.addEvent(this.frame,'load',this.bindMethod(this.setTimer,this));var self=this;if(window.chrome!==undefined){this.frame.onload=function(){try{var doc=this.contentWindow.document;var _jotform=this.contentWindow.JotForm;if(doc!==undefined){var form=doc.getElementById(""+self.iframeDomId);self.addEvent(form,"submit",function(){if(_jotform.validateAll()){self.formSubmitted=1;}});}}catch(e){}}}};this.addEvent=function(obj,type,fn){if(obj.attachEvent){obj["e"+type+fn]=fn;obj[type+fn]=function(){obj["e"+type+fn](window.event);};obj.attachEvent("on"+type,obj[type+fn]);}
else{obj.addEventListener(type,fn,false);}};this.addFrameContent=function(string){if(window.location.search&&window.location.search.indexOf('disableSmartEmbed')>-1){string=string.replace(new RegExp('smartEmbed=1(?:&amp;|&)'),'');string=string.replace(new RegExp('isSmartEmbed'),'');}else{var cssLink='stylebuilder/'+this.formId+'.css';var cssPlace=string.indexOf(cssLink);var prepend=string[cssPlace+cssLink.length]==='?'?'&amp;':'?';var embedUrl=prepend+'embedUrl='+window.location.href;if(cssPlace>-1){var positionLastRequestElement=string.indexOf('\"/>',cssPlace);if(positionLastRequestElement>-1){string=string.substr(0,positionLastRequestElement)+embedUrl+string.substr(positionLastRequestElement);string=string.replace(cssLink,'stylebuilder/'+this.formId+'/'+this.embedURLHash+'.css');}}}
string=string.replace(new RegExp('src\\=\\"[^"]*captcha.php\"><\/scr'+'ipt>','gim'),'src="http://api.recaptcha.net/js/recaptcha_ajax.js"></scr'+'ipt><'+'div id="recaptcha_div"><'+'/div>'+'<'+'style>#recaptcha_logo{ display:none;} #recaptcha_tagline{display:none;} #recaptcha_table{border:none !important;} .recaptchatable .recaptcha_image_cell, #recaptcha_table{ background-color:transparent !important; } <'+'/style>'+'<'+'script defer="defer"> window.onload = function(){ Recaptcha.create("6Ld9UAgAAAAAAMon8zjt30tEZiGQZ4IIuWXLt1ky", "recaptcha_div", {theme: "clean",tabindex: 0,callback: function (){'+'if (document.getElementById("uword")) { document.getElementById("uword").parentNode.removeChild(document.getElementById("uword")); } if (window["validate"] !== undefined) { if (document.getElementById("recaptcha_response_field")){ document.getElementById("recaptcha_response_field").onblur = function(){ validate(document.getElementById("recaptcha_response_field"), "Required"); } } } if (document.getElementById("recaptcha_response_field")){ document.getElementsByName("recaptcha_challenge_field")[0].setAttribute("name", "anum"); } if (document.getElementById("recaptcha_response_field")){ document.getElementsByName("recaptcha_response_field")[0].setAttribute("name", "qCap"); }}})'+' }<'+'/script>');string=string.replace(/(type="text\/javascript">)\s+(validate\(\"[^"]*"\);)/,'$1 jTime = setInterval(function(){if("validate" in window){$2clearTimeout(jTime);}}, 1000);');if(string.match('#sublabel_litemode')){string=string.replace('class="form-all"','class="form-all" style="margin-top:0;"');}
var iframe=this.frame;var doc=iframe.contentDocument?iframe.contentDocument:(iframe.contentWindow.document||iframe.document);doc.open();doc.write(string);setTimeout(function(){doc.close();try{if('JotFormFrameLoaded'in window){JotFormFrameLoaded();}}catch(e){}},200);};this.setTimer=function(){var self=this;this.interval=setTimeout(this.changeHeight.bind(this),this.timeInterval);};this.getBaseDomain=function(){var thn=window.location.hostname;var cc=0;var buff="";for(var i=0;i<thn.length;i++){var chr=thn.charAt(i);if(chr=="."){cc++;}
if(cc==0){buff+=chr;}}
if(cc==2){thn=thn.replace(buff+".","");}
return thn;}
this.changeHeight=function(){var actualHeight=this.getBodyHeight();var currentHeight=this.getViewPortHeight();var skipAutoHeight=(this.frame.contentWindow)?this.frame.contentWindow.document.querySelector('[data-welcome-view="true"]'):null;if(actualHeight===undefined){this.frame.style.height=this.frameHeight;if(!this.frame.style.minHeight){this.frame.style.minHeight="100vh";if(!('nojump'in this.frame.contentWindow.document.get)){window.parent.scrollTo(0,0);}}else if(!this.frame.dataset.parentScrolled){this.frame.dataset.parentScrolled=true;var container=window.parent.document&&window.parent.document.querySelector('.jt-content');if(container&&!('nojump'in window.parent.document.get)){container.scrollTo(0,0);}}}else if(Math.abs(actualHeight-currentHeight)>18&&!skipAutoHeight){this.frame.style.height=(actualHeight)+"px";}
this.setTimer();};this.bindMethod=function(method,scope){return function(){method.apply(scope,arguments);};};this.frameHeight=0;this.getBodyHeight=function(){if(this.formSubmitted===1){return;}
var height;var scrollHeight;var offsetHeight;try{if(this.frame.contentWindow.document.height){height=this.frame.contentWindow.document.height;if(this.frame.contentWindow.document.body.scrollHeight){height=scrollHeight=this.frame.contentWindow.document.body.scrollHeight;}
if(this.frame.contentWindow.document.body.offsetHeight){height=offsetHeight=this.frame.contentWindow.document.body.offsetHeight;}}else if(this.frame.contentWindow.document.body){if(this.frame.contentWindow.document.body.offsetHeight){height=offsetHeight=this.frame.contentWindow.document.body.offsetHeight;}
var formWrapper=this.frame.contentWindow.document.querySelector('.form-all');var margin=parseInt(getComputedStyle(formWrapper).marginTop,10);if(!isNaN(margin)){height+=margin;}}}catch(e){}
this.frameHeight=height;return height;};this.getViewPortHeight=function(){if(this.formSubmitted===1){return;}
var height=0;try{if(this.frame.contentWindow.window.innerHeight){height=this.frame.contentWindow.window.innerHeight-18;}else if((this.frame.contentWindow.document.documentElement)&&(this.frame.contentWindow.document.documentElement.clientHeight)){height=this.frame.contentWindow.document.documentElement.clientHeight;}else if((this.frame.contentWindow.document.body)&&(this.frame.contentWindow.document.body.clientHeight)){height=this.frame.contentWindow.document.body.clientHeight;}}catch(e){}
return height;};this.getMD5=function(s){function L(k,d){return(k<<d)|(k>>>(32-d))}function K(G,k){var I,d,F,H,x;F=(G&2147483648);H=(k&2147483648);I=(G&1073741824);d=(k&1073741824);x=(G&1073741823)+(k&1073741823);if(I&d){return(x^2147483648^F^H)}if(I|d){if(x&1073741824){return(x^3221225472^F^H)}else{return(x^1073741824^F^H)}}else{return(x^F^H)}}function r(d,F,k){return(d&F)|((~d)&k)}function q(d,F,k){return(d&k)|(F&(~k))}function p(d,F,k){return(d^F^k)}function n(d,F,k){return(F^(d|(~k)))}function u(G,F,aa,Z,k,H,I){G=K(G,K(K(r(F,aa,Z),k),I));return K(L(G,H),F)}function f(G,F,aa,Z,k,H,I){G=K(G,K(K(q(F,aa,Z),k),I));return K(L(G,H),F)}function D(G,F,aa,Z,k,H,I){G=K(G,K(K(p(F,aa,Z),k),I));return K(L(G,H),F)}function t(G,F,aa,Z,k,H,I){G=K(G,K(K(n(F,aa,Z),k),I));return K(L(G,H),F)}function e(G){var Z;var F=G.length;var x=F+8;var k=(x-(x%64))/64;var I=(k+1)*16;var aa=Array(I-1);var d=0;var H=0;while(H<F){Z=(H-(H%4))/4;d=(H%4)*8;aa[Z]=(aa[Z]|(G.charCodeAt(H)<<d));H++}Z=(H-(H%4))/4;d=(H%4)*8;aa[Z]=aa[Z]|(128<<d);aa[I-2]=F<<3;aa[I-1]=F>>>29;return aa}function B(x){var k="",F="",G,d;for(d=0;d<=3;d++){G=(x>>>(d*8))&255;F="0"+G.toString(16);k=k+F.substr(F.length-2,2)}return k}function J(k){k=k.replace(/rn/g,"n");var d="";for(var F=0;F<k.length;F++){var x=k.charCodeAt(F);if(x<128){d+=String.fromCharCode(x)}else{if((x>127)&&(x<2048)){d+=String.fromCharCode((x>>6)|192);d+=String.fromCharCode((x&63)|128)}else{d+=String.fromCharCode((x>>12)|224);d+=String.fromCharCode(((x>>6)&63)|128);d+=String.fromCharCode((x&63)|128)}}}return d}var C=Array();var P,h,E,v,g,Y,X,W,V;var S=7,Q=12,N=17,M=22;var A=5,z=9,y=14,w=20;var o=4,m=11,l=16,j=23;var U=6,T=10,R=15,O=21;s=J(s);C=e(s);Y=1732584193;X=4023233417;W=2562383102;V=271733878;for(P=0;P<C.length;P+=16){h=Y;E=X;v=W;g=V;Y=u(Y,X,W,V,C[P+0],S,3614090360);V=u(V,Y,X,W,C[P+1],Q,3905402710);W=u(W,V,Y,X,C[P+2],N,606105819);X=u(X,W,V,Y,C[P+3],M,3250441966);Y=u(Y,X,W,V,C[P+4],S,4118548399);V=u(V,Y,X,W,C[P+5],Q,1200080426);W=u(W,V,Y,X,C[P+6],N,2821735955);X=u(X,W,V,Y,C[P+7],M,4249261313);Y=u(Y,X,W,V,C[P+8],S,1770035416);V=u(V,Y,X,W,C[P+9],Q,2336552879);W=u(W,V,Y,X,C[P+10],N,4294925233);X=u(X,W,V,Y,C[P+11],M,2304563134);Y=u(Y,X,W,V,C[P+12],S,1804603682);V=u(V,Y,X,W,C[P+13],Q,4254626195);W=u(W,V,Y,X,C[P+14],N,2792965006);X=u(X,W,V,Y,C[P+15],M,1236535329);Y=f(Y,X,W,V,C[P+1],A,4129170786);V=f(V,Y,X,W,C[P+6],z,3225465664);W=f(W,V,Y,X,C[P+11],y,643717713);X=f(X,W,V,Y,C[P+0],w,3921069994);Y=f(Y,X,W,V,C[P+5],A,3593408605);V=f(V,Y,X,W,C[P+10],z,38016083);W=f(W,V,Y,X,C[P+15],y,3634488961);X=f(X,W,V,Y,C[P+4],w,3889429448);Y=f(Y,X,W,V,C[P+9],A,568446438);V=f(V,Y,X,W,C[P+14],z,3275163606);W=f(W,V,Y,X,C[P+3],y,4107603335);X=f(X,W,V,Y,C[P+8],w,1163531501);Y=f(Y,X,W,V,C[P+13],A,2850285829);V=f(V,Y,X,W,C[P+2],z,4243563512);W=f(W,V,Y,X,C[P+7],y,1735328473);X=f(X,W,V,Y,C[P+12],w,2368359562);Y=D(Y,X,W,V,C[P+5],o,4294588738);V=D(V,Y,X,W,C[P+8],m,2272392833);W=D(W,V,Y,X,C[P+11],l,1839030562);X=D(X,W,V,Y,C[P+14],j,4259657740);Y=D(Y,X,W,V,C[P+1],o,2763975236);V=D(V,Y,X,W,C[P+4],m,1272893353);W=D(W,V,Y,X,C[P+7],l,4139469664);X=D(X,W,V,Y,C[P+10],j,3200236656);Y=D(Y,X,W,V,C[P+13],o,681279174);V=D(V,Y,X,W,C[P+0],m,3936430074);W=D(W,V,Y,X,C[P+3],l,3572445317);X=D(X,W,V,Y,C[P+6],j,76029189);Y=D(Y,X,W,V,C[P+9],o,3654602809);V=D(V,Y,X,W,C[P+12],m,3873151461);W=D(W,V,Y,X,C[P+15],l,530742520);X=D(X,W,V,Y,C[P+2],j,3299628645);Y=t(Y,X,W,V,C[P+0],U,4096336452);V=t(V,Y,X,W,C[P+7],T,1126891415);W=t(W,V,Y,X,C[P+14],R,2878612391);X=t(X,W,V,Y,C[P+5],O,4237533241);Y=t(Y,X,W,V,C[P+12],U,1700485571);V=t(V,Y,X,W,C[P+3],T,2399980690);W=t(W,V,Y,X,C[P+10],R,4293915773);X=t(X,W,V,Y,C[P+1],O,2240044497);Y=t(Y,X,W,V,C[P+8],U,1873313359);V=t(V,Y,X,W,C[P+15],T,4264355552);W=t(W,V,Y,X,C[P+6],R,2734768916);X=t(X,W,V,Y,C[P+13],O,1309151649);Y=t(Y,X,W,V,C[P+4],U,4149444226);V=t(V,Y,X,W,C[P+11],T,3174756917);W=t(W,V,Y,X,C[P+2],R,718787259);X=t(X,W,V,Y,C[P+9],O,3951481745);Y=K(Y,h);X=K(X,E);W=K(W,v);V=K(V,g)}var i=B(Y)+B(X)+B(W)+B(V);return i.toLowerCase()};this.init();}
FrameBuilder.get=qsProxy||[];var i212695859147167=new FrameBuilder("212695859147167",false,"","<!DOCTYPE HTML PUBLIC \"-\/\/W3C\/\/DTD HTML 4.01\/\/EN\" \"http:\/\/www.w3.org\/TR\/html4\/strict.dtd\">\n<html lang=\"en-US\"  class=\"supernova\"><head><script>console.warn(\"Server Side Rendering => render-from: frontend\");<\/script>\n<meta http-equiv=\"Content-Type\" content=\"text\/html; charset=utf-8\" \/>\n<link rel=\"alternate\" type=\"application\/json+oembed\" href=\"https:\/\/www.jotform.com\/oembed\/?format=json&amp;url=https%3A%2F%2Fform.jotform.com%2F212695859147167\" title=\"oEmbed Form\">\n<link rel=\"alternate\" type=\"text\/xml+oembed\" href=\"https:\/\/www.jotform.com\/oembed\/?format=xml&amp;url=https%3A%2F%2Fform.jotform.com%2F212695859147167\" title=\"oEmbed Form\">\n<meta property=\"og:title\" content=\"Weehawken Vaccine V3\" >\n<meta property=\"og:url\" content=\"https:\/\/form.jotform.com\/212695859147167\" >\n<meta property=\"og:description\" content=\"Please click the link to complete this form.\" >\n<meta name=\"slack-app-id\" content=\"AHNMASS8M\">\n<meta data-name=\"preventCloning\" content=\"1\">\n<link rel=\"shortcut icon\" href=\"https:\/\/cdn.jotfor.ms\/assets\/img\/favicons\/favicon-2021.svg\">\n<meta property=\"og:image\" content=\"https:\/\/cdn.jotfor.ms\/assets\/img\/favicons\/favicon-2021.svg\" \/>\n<link rel=\"canonical\" href=\"https:\/\/form.jotform.com\/212695859147167\" \/>\n<meta name=\"viewport\" content=\"width=device-width, initial-scale=1.0, maximum-scale=2.0, user-scalable=1\" \/>\n<meta name=\"HandheldFriendly\" content=\"true\" \/>\n<title>Weehawken Vaccine V3<\/title>\n<style type=\"text\/css\">@media print{.form-section{display:inline!important}.form-pagebreak{display:none!important}.form-section-closed{height:auto!important}.page-section{position:initial!important}}<\/style>\n<link type=\"text\/css\" rel=\"stylesheet\" href=\"https:\/\/cdn01.jotfor.ms\/themes\/CSS\/5e6b428acc8c4e222d1beb91.css?themeRevisionID=5f7ed99c2c2c7240ba580251\"\/>\n<link type=\"text\/css\" rel=\"stylesheet\" href=\"https:\/\/cdn02.jotfor.ms\/css\/styles\/payment\/payment_styles.css?3.3.35816\" \/>\n<link type=\"text\/css\" rel=\"stylesheet\" href=\"https:\/\/cdn03.jotfor.ms\/css\/styles\/payment\/payment_feature.css?3.3.35816\" \/>\n<script src=\"https:\/\/cdn01.jotfor.ms\/static\/prototype.forms.js?3.3.35816\" type=\"text\/javascript\"><\/script>\n<script src=\"https:\/\/cdn02.jotfor.ms\/static\/jotform.forms.js?3.3.35816\" type=\"text\/javascript\"><\/script>\n<script defer src=\"https:\/\/cdnjs.cloudflare.com\/ajax\/libs\/punycode\/1.4.1\/punycode.js\"><\/script>\n<script src=\"https:\/\/cdn03.jotfor.ms\/js\/vendor\/jquery-1.8.0.min.js?v=3.3.35816\" type=\"text\/javascript\"><\/script>\n<script defer src=\"https:\/\/cdn01.jotfor.ms\/js\/vendor\/maskedinput.min.js?v=3.3.35816\" type=\"text\/javascript\"><\/script>\n<script defer src=\"https:\/\/cdn02.jotfor.ms\/js\/vendor\/jquery.maskedinput.min.js?v=3.3.35816\" type=\"text\/javascript\"><\/script>\n<script src=\"https:\/\/cdn03.jotfor.ms\/\/s\/umd\/ie11\/for-appointment-field.js\" type=\"text\/javascript\"><\/script>\n<script type=\"text\/javascript\">\tJotForm.newDefaultTheme = true;\n\tJotForm.extendsNewTheme = false;\n\tJotForm.newPaymentUIForNewCreatedForms = true;\n\tJotForm.newPaymentUI = true;\n\n var jsTime = setInterval(function(){try{\n   JotForm.jsForm = true;\n\n   JotForm.setConditions([{\"action\":[{\"id\":\"action_0_1636316824448\",\"visibility\":\"Show\",\"isError\":false,\"field\":\"49\"}],\"id\":\"1636316718863\",\"index\":\"1\",\"link\":\"Any\",\"priority\":\"1\",\"terms\":[{\"id\":\"term_0_1636316824448\",\"field\":\"9\",\"operator\":\"equals\",\"value\":\"Johnson & Johnson Vaccine - Weehawken Location\",\"isError\":false}],\"type\":\"field\"},{\"action\":[{\"id\":\"action_0_1636316890245\",\"visibility\":\"Show\",\"isError\":false,\"field\":\"14\"}],\"id\":\"1636316884278\",\"index\":\"2\",\"link\":\"Any\",\"priority\":\"2\",\"terms\":[{\"id\":\"term_0_1636316890245\",\"field\":\"9\",\"operator\":\"equals\",\"value\":\"Moderna Vaccine - Weehawken Location\",\"isError\":false}],\"type\":\"field\"},{\"action\":[{\"id\":\"action_0_1637593312058\",\"visibility\":\"Show\",\"isError\":false,\"field\":\"50\"}],\"id\":\"1636316888591\",\"index\":\"3\",\"link\":\"Any\",\"priority\":\"3\",\"terms\":[{\"id\":\"term_0_1637593312058\",\"field\":\"9\",\"operator\":\"equals\",\"value\":\"Pfizer Children's Vaccine - 5 to 11 Years Old\",\"isError\":false}],\"type\":\"field\"},{\"action\":[{\"id\":\"action_0_1637593329187\",\"visibility\":\"Show\",\"isError\":false,\"field\":\"7\"}],\"id\":\"1637593326748\",\"index\":\"4\",\"link\":\"Any\",\"priority\":\"4\",\"terms\":[{\"id\":\"term_0_1637593329187\",\"field\":\"9\",\"operator\":\"equals\",\"value\":\"Pfizer Vaccine - Weehawken Location\",\"isError\":false}],\"type\":\"field\"},{\"action\":[{\"id\":\"action_1618190191170\",\"visibility\":\"Show\",\"isError\":false,\"field\":\"29\"}],\"id\":\"1618190202546\",\"index\":\"39\",\"link\":\"Any\",\"priority\":\"39\",\"terms\":[{\"id\":\"term_1618190191170\",\"field\":\"28\",\"operator\":\"equals\",\"value\":\"United States\",\"isError\":false}],\"type\":\"field\"}]);\tJotForm.clearFieldOnHide=\"enable\";\n\tJotForm.submitError=\"jumpToFirstError\";\n\n\tJotForm.init(function(){\n\t\/*INIT-START*\/\n     $('input_4_confirm').hint('example@example.com');\n     $$('#input_4_confirm')[0].setAttribute('onPaste', 'return false;');\n      JotForm.setPhoneMaskingValidator( 'input_6_full', '(###) ###-####' );\n\n JotForm.calendarMonths = [\"January\",\"February\",\"March\",\"April\",\"May\",\"June\",\"July\",\"August\",\"September\",\"October\",\"November\",\"December\"];\n JotForm.calendarDays = [\"Sunday\",\"Monday\",\"Tuesday\",\"Wednesday\",\"Thursday\",\"Friday\",\"Saturday\",\"Sunday\"];\n JotForm.calendarOther = {\"today\":\"Today\"};\n var languageOptions = document.querySelectorAll('#langList li'); \n for(var langIndex = 0; langIndex < languageOptions.length; langIndex++) { \n   languageOptions[langIndex].on('click', function(e) { setTimeout(function(){ JotForm.setCalendar(\"10\", false, {\"days\":{\"monday\":true,\"tuesday\":true,\"wednesday\":true,\"thursday\":true,\"friday\":true,\"saturday\":true,\"sunday\":true},\"future\":false,\"past\":true,\"custom\":false,\"ranges\":false,\"start\":\"\",\"end\":\"\"}); }, 0); });\n } \n JotForm.onTranslationsFetch(function() { JotForm.setCalendar(\"10\", false, {\"days\":{\"monday\":true,\"tuesday\":true,\"wednesday\":true,\"thursday\":true,\"friday\":true,\"saturday\":true,\"sunday\":true},\"future\":false,\"past\":true,\"custom\":false,\"ranges\":false,\"start\":\"\",\"end\":\"\"}); });\n\n    JotForm.calendarMonths = [\"January\",\"February\",\"March\",\"April\",\"May\",\"June\",\"July\",\"August\",\"September\",\"October\",\"November\",\"December\"];\n    JotForm.appointmentCalendarDays = [\"Monday\",\"Tuesday\",\"Wednesday\",\"Thursday\",\"Friday\",\"Saturday\",\"Sunday\"];\n    JotForm.calendarOther = \"Today\";\n    window.initializeAppointment({\"text\":{\"text\":\"Question\",\"value\":\"Pfizer Vaccine - Weehawken Location\"},\"labelAlign\":{\"text\":\"Label Align\",\"value\":\"Top\",\"dropdown\":[[\"Auto\",\"Auto\"],[\"Left\",\"Left\"],[\"Right\",\"Right\"],[\"Top\",\"Top\"]]},\"required\":{\"text\":\"Required\",\"value\":\"Yes\",\"dropdown\":[[\"No\",\"No\"],[\"Yes\",\"Yes\"]]},\"description\":{\"text\":\"Hover Text\",\"value\":\"\",\"textarea\":true},\"slotDuration\":{\"text\":\"Slot Duration\",\"value\":\"15\",\"dropdown\":[[15,\"15 min\"],[30,\"30 min\"],[45,\"45 min\"],[60,\"60 min\"],[\"custom\",\"Custom min\"]],\"hint\":\"Select how long each slot will be.\"},\"startDate\":{\"text\":\"Start Date\",\"value\":\"2022-09-11\"},\"endDate\":{\"text\":\"End Date\",\"value\":\"2022-09-30\"},\"intervals\":{\"text\":\"Intervals\",\"value\":[{\"from\":\"15:00\",\"to\":\"19:00\",\"days\":[\"Wed\"]}],\"hint\":\"The hours will be applied to the selected days and repeated.\"},\"useBlockout\":{\"text\":\"Blockout Custom Dates\",\"value\":\"No\",\"dropdown\":[[\"No\",\"No\"],[\"Yes\",\"Yes\"]],\"hint\":\"Disable certain date(s) in the calendar.\"},\"blockoutDates\":{\"text\":\"Blockout dates\",\"value\":[{\"startDate\":\"\",\"endDate\":\"\"}]},\"useLunchBreak\":{\"text\":\"Lunch Time\",\"value\":\"No\",\"dropdown\":[[\"No\",\"No\"],[\"Yes\",\"Yes\"]],\"hint\":\"Enable lunchtime in the calendar.\"},\"lunchBreak\":{\"text\":\"Lunchtime hours\",\"value\":[{\"from\":\"12:00\",\"to\":\"14:00\"}]},\"timezone\":{\"text\":\"Timezone\",\"value\":\"America\/New_York (GMT-04:00)\"},\"timeFormat\":{\"text\":\"Time Format\",\"value\":\"AM\/PM\",\"dropdown\":[[\"24 Hour\",\"24 Hour\"],[\"AM\/PM\",\"AM\/PM\"]],\"icon\":\"images\/blank.gif\",\"iconClassName\":\"toolbar-time_format_24\"},\"months\":{\"value\":[\"January\",\"February\",\"March\",\"April\",\"May\",\"June\",\"July\",\"August\",\"September\",\"October\",\"November\",\"December\"],\"hidden\":true},\"days\":{\"value\":[\"Monday\",\"Tuesday\",\"Wednesday\",\"Thursday\",\"Friday\",\"Saturday\",\"Sunday\"],\"hidden\":true},\"startWeekOn\":{\"text\":\"Start Week On\",\"value\":\"Sunday\",\"dropdown\":[[\"Monday\",\"Monday\"],[\"Sunday\",\"Sunday\"]],\"toolbar\":false},\"rollingDays\":{\"text\":\"Rolling Days\",\"value\":\"14\",\"toolbar\":false},\"prevMonthButtonText\":{\"text\":\"Previous month\",\"value\":\"\"},\"nextMonthButtonText\":{\"text\":\"Next month\",\"value\":\"\"},\"prevYearButtonText\":{\"text\":\"Previous year\",\"value\":\"\"},\"nextYearButtonText\":{\"text\":\"Next year\",\"value\":\"\"},\"prevDayButtonText\":{\"text\":\"Previous day\",\"value\":\"\"},\"nextDayButtonText\":{\"text\":\"Next day\",\"value\":\"\"},\"appointmentType\":{\"hidden\":true,\"value\":\"multiple\"},\"autoDetectTimezone\":{\"hidden\":true,\"value\":\"Yes\"},\"dateFormat\":{\"hidden\":true,\"value\":\"mm\/dd\/yyyy\"},\"hidden\":{\"hidden\":true,\"value\":\"Yes\"},\"maxAttendee\":{\"hidden\":true,\"value\":\"6\"},\"maxEvents\":{\"hidden\":true,\"value\":\"40\"},\"minScheduleNotice\":{\"hidden\":true,\"value\":\"6\"},\"name\":{\"hidden\":true,\"value\":\"pfizerVaccine\"},\"order\":{\"hidden\":true,\"value\":\"21\"},\"qid\":{\"toolbar\":false,\"value\":\"input_7\"},\"reminderEmails\":{\"hidden\":true,\"value\":{\"schedule\":[{\"value\":\"2\",\"unit\":\"hour\"}]}},\"type\":{\"hidden\":true,\"value\":\"control_appointment\"},\"useReminderEmails\":{\"hidden\":true,\"value\":\"No\"},\"id\":{\"toolbar\":false,\"value\":\"7\"},\"qname\":{\"toolbar\":false,\"value\":\"q7_pfizerVaccine\"},\"cdnconfig\":{\"CDN\":\"https:\/\/cdn.jotfor.ms\/\"},\"passive\":false,\"formProperties\":{\"products\":false,\"highlightLine\":\"Enabled\",\"coupons\":false,\"useStripeCoupons\":false,\"taxes\":false,\"comparePaymentForm\":\"\",\"paymentListSettings\":false,\"newPaymentUIForNewCreatedForms\":\"Yes\",\"formBackground\":\"#fff\"},\"formID\":212695859147167,\"isPaymentForm\":false,\"isOpenedInPortal\":false,\"isCheckoutForm\":false,\"cartProducts\":[],\"isFastCheckoutShoppingApp\":false,\"translatedProductListTexts\":false,\"productListColors\":false,\"themeVersion\":\"v2\"});\n  \n    JotForm.calendarMonths = [\"January\",\"February\",\"March\",\"April\",\"May\",\"June\",\"July\",\"August\",\"September\",\"October\",\"November\",\"December\"];\n    JotForm.appointmentCalendarDays = [\"Monday\",\"Tuesday\",\"Wednesday\",\"Thursday\",\"Friday\",\"Saturday\",\"Sunday\"];\n    JotForm.calendarOther = \"Today\";\n    window.initializeAppointment({\"text\":{\"text\":\"Question\",\"value\":\"Pfizer Children's Vaccine- 5 to 11 Years Old\"},\"labelAlign\":{\"text\":\"Label Align\",\"value\":\"Top\",\"dropdown\":[[\"Auto\",\"Auto\"],[\"Left\",\"Left\"],[\"Right\",\"Right\"],[\"Top\",\"Top\"]]},\"required\":{\"text\":\"Required\",\"value\":\"Yes\",\"dropdown\":[[\"No\",\"No\"],[\"Yes\",\"Yes\"]]},\"description\":{\"text\":\"Hover Text\",\"value\":\"\",\"textarea\":true},\"slotDuration\":{\"text\":\"Slot Duration\",\"value\":\"15\",\"dropdown\":[[15,\"15 min\"],[30,\"30 min\"],[45,\"45 min\"],[60,\"60 min\"],[\"custom\",\"Custom min\"]],\"hint\":\"Select how long each slot will be.\"},\"startDate\":{\"text\":\"Start Date\",\"value\":\"2022-09-11\"},\"endDate\":{\"text\":\"End Date\",\"value\":\"2022-09-30\"},\"intervals\":{\"text\":\"Intervals\",\"value\":[{\"from\":\"15:00\",\"to\":\"19:00\",\"days\":[\"Wed\"]}],\"hint\":\"The hours will be applied to the selected days and repeated.\"},\"useBlockout\":{\"text\":\"Blockout Custom Dates\",\"value\":\"No\",\"dropdown\":[[\"No\",\"No\"],[\"Yes\",\"Yes\"]],\"hint\":\"Disable certain date(s) in the calendar.\"},\"blockoutDates\":{\"text\":\"Blockout dates\",\"value\":[{\"startDate\":\"2022-04-15\",\"endDate\":\"2022-04-15\"}]},\"useLunchBreak\":{\"text\":\"Lunch Time\",\"value\":\"No\",\"dropdown\":[[\"No\",\"No\"],[\"Yes\",\"Yes\"]],\"hint\":\"Enable lunchtime in the calendar.\"},\"lunchBreak\":{\"text\":\"Lunchtime hours\",\"value\":[{\"from\":\"12:00\",\"to\":\"14:00\"}]},\"timezone\":{\"text\":\"Timezone\",\"value\":\"America\/New_York (GMT-05:00)\"},\"timeFormat\":{\"text\":\"Time Format\",\"value\":\"AM\/PM\",\"dropdown\":[[\"24 Hour\",\"24 Hour\"],[\"AM\/PM\",\"AM\/PM\"]],\"icon\":\"images\/blank.gif\",\"iconClassName\":\"toolbar-time_format_24\"},\"months\":{\"value\":[\"January\",\"February\",\"March\",\"April\",\"May\",\"June\",\"July\",\"August\",\"September\",\"October\",\"November\",\"December\"],\"hidden\":true},\"days\":{\"value\":[\"Monday\",\"Tuesday\",\"Wednesday\",\"Thursday\",\"Friday\",\"Saturday\",\"Sunday\"],\"hidden\":true},\"startWeekOn\":{\"text\":\"Start Week On\",\"value\":\"Sunday\",\"dropdown\":[[\"Monday\",\"Monday\"],[\"Sunday\",\"Sunday\"]],\"toolbar\":false},\"rollingDays\":{\"text\":\"Rolling Days\",\"value\":\"14\",\"toolbar\":false},\"prevMonthButtonText\":{\"text\":\"Previous month\",\"value\":\"\"},\"nextMonthButtonText\":{\"text\":\"Next month\",\"value\":\"\"},\"prevYearButtonText\":{\"text\":\"Previous year\",\"value\":\"\"},\"nextYearButtonText\":{\"text\":\"Next year\",\"value\":\"\"},\"prevDayButtonText\":{\"text\":\"Previous day\",\"value\":\"\"},\"nextDayButtonText\":{\"text\":\"Next day\",\"value\":\"\"},\"appointmentType\":{\"hidden\":true,\"value\":\"multiple\"},\"autoDetectTimezone\":{\"hidden\":true,\"value\":\"Yes\"},\"dateFormat\":{\"hidden\":true,\"value\":\"mm\/dd\/yyyy\"},\"hidden\":{\"hidden\":true,\"value\":\"Yes\"},\"maxAttendee\":{\"hidden\":true,\"value\":\"4\"},\"maxEvents\":{\"hidden\":true,\"value\":\"20\"},\"minScheduleNotice\":{\"hidden\":true,\"value\":\"6\"},\"name\":{\"hidden\":true,\"value\":\"pfizerChildrens\"},\"order\":{\"hidden\":true,\"value\":\"22\"},\"qid\":{\"toolbar\":false,\"value\":\"input_50\"},\"reminderEmails\":{\"hidden\":true,\"value\":{\"schedule\":[{\"value\":\"2\",\"unit\":\"hour\"}]}},\"type\":{\"hidden\":true,\"value\":\"control_appointment\"},\"useReminderEmails\":{\"hidden\":true,\"value\":\"No\"},\"id\":{\"toolbar\":false,\"value\":\"50\"},\"qname\":{\"toolbar\":false,\"value\":\"q50_pfizerChildrens\"},\"cdnconfig\":{\"CDN\":\"https:\/\/cdn.jotfor.ms\/\"},\"passive\":false,\"formProperties\":{\"products\":false,\"highlightLine\":\"Enabled\",\"coupons\":false,\"useStripeCoupons\":false,\"taxes\":false,\"comparePaymentForm\":\"\",\"paymentListSettings\":false,\"newPaymentUIForNewCreatedForms\":\"Yes\",\"formBackground\":\"#fff\"},\"formID\":212695859147167,\"isPaymentForm\":false,\"isOpenedInPortal\":false,\"isCheckoutForm\":false,\"cartProducts\":[],\"isFastCheckoutShoppingApp\":false,\"translatedProductListTexts\":false,\"productListColors\":false,\"themeVersion\":\"v2\"});\n  \n    JotForm.calendarMonths = [\"January\",\"February\",\"March\",\"April\",\"May\",\"June\",\"July\",\"August\",\"September\",\"October\",\"November\",\"December\"];\n    JotForm.appointmentCalendarDays = [\"Monday\",\"Tuesday\",\"Wednesday\",\"Thursday\",\"Friday\",\"Saturday\",\"Sunday\"];\n    JotForm.calendarOther = \"Today\";\n    window.initializeAppointment({\"text\":{\"text\":\"Question\",\"value\":\"Johnson & Johnson - Weehawken Location\"},\"labelAlign\":{\"text\":\"Label Align\",\"value\":\"Top\",\"dropdown\":[[\"Auto\",\"Auto\"],[\"Left\",\"Left\"],[\"Right\",\"Right\"],[\"Top\",\"Top\"]]},\"required\":{\"text\":\"Required\",\"value\":\"Yes\",\"dropdown\":[[\"No\",\"No\"],[\"Yes\",\"Yes\"]]},\"description\":{\"text\":\"Hover Text\",\"value\":\"\",\"textarea\":true},\"slotDuration\":{\"text\":\"Slot Duration\",\"value\":\"15\",\"dropdown\":[[15,\"15 min\"],[30,\"30 min\"],[45,\"45 min\"],[60,\"60 min\"],[\"custom\",\"Custom min\"]],\"hint\":\"Select how long each slot will be.\"},\"startDate\":{\"text\":\"Start Date\",\"value\":\"2022-01-06\"},\"endDate\":{\"text\":\"End Date\",\"value\":\"2022-01-08\"},\"intervals\":{\"text\":\"Intervals\",\"value\":[{\"from\":\"16:00\",\"to\":\"17:00\",\"days\":[\"Fri\"]}],\"hint\":\"The hours will be applied to the selected days and repeated.\"},\"useBlockout\":{\"text\":\"Blockout Custom Dates\",\"value\":\"No\",\"dropdown\":[[\"No\",\"No\"],[\"Yes\",\"Yes\"]],\"hint\":\"Disable certain date(s) in the calendar.\"},\"blockoutDates\":{\"text\":\"Blockout dates\",\"value\":[{\"startDate\":\"\",\"endDate\":\"\"}]},\"useLunchBreak\":{\"text\":\"Lunch Time\",\"value\":\"No\",\"dropdown\":[[\"No\",\"No\"],[\"Yes\",\"Yes\"]],\"hint\":\"Enable lunchtime in the calendar.\"},\"lunchBreak\":{\"text\":\"Lunchtime hours\",\"value\":[{\"from\":\"12:00\",\"to\":\"14:00\"}]},\"timezone\":{\"text\":\"Timezone\",\"value\":\"America\/New_York (GMT-05:00)\"},\"timeFormat\":{\"text\":\"Time Format\",\"value\":\"AM\/PM\",\"dropdown\":[[\"24 Hour\",\"24 Hour\"],[\"AM\/PM\",\"AM\/PM\"]],\"icon\":\"images\/blank.gif\",\"iconClassName\":\"toolbar-time_format_24\"},\"months\":{\"value\":[\"January\",\"February\",\"March\",\"April\",\"May\",\"June\",\"July\",\"August\",\"September\",\"October\",\"November\",\"December\"],\"hidden\":true},\"days\":{\"value\":[\"Monday\",\"Tuesday\",\"Wednesday\",\"Thursday\",\"Friday\",\"Saturday\",\"Sunday\"],\"hidden\":true},\"startWeekOn\":{\"text\":\"Start Week On\",\"value\":\"Sunday\",\"dropdown\":[[\"Monday\",\"Monday\"],[\"Sunday\",\"Sunday\"]],\"toolbar\":false},\"rollingDays\":{\"text\":\"Rolling Days\",\"value\":\"7\",\"toolbar\":false},\"prevMonthButtonText\":{\"text\":\"Previous month\",\"value\":\"\"},\"nextMonthButtonText\":{\"text\":\"Next month\",\"value\":\"\"},\"prevYearButtonText\":{\"text\":\"Previous year\",\"value\":\"\"},\"nextYearButtonText\":{\"text\":\"Next year\",\"value\":\"\"},\"prevDayButtonText\":{\"text\":\"Previous day\",\"value\":\"\"},\"nextDayButtonText\":{\"text\":\"Next day\",\"value\":\"\"},\"appointmentType\":{\"hidden\":true,\"value\":\"multiple\"},\"autoDetectTimezone\":{\"hidden\":true,\"value\":\"Yes\"},\"dateFormat\":{\"hidden\":true,\"value\":\"mm\/dd\/yyyy\"},\"hidden\":{\"hidden\":true,\"value\":\"Yes\"},\"maxAttendee\":{\"hidden\":true,\"value\":\"5\"},\"maxEvents\":{\"hidden\":true,\"value\":\"10\"},\"minScheduleNotice\":{\"hidden\":true,\"value\":\"10\"},\"name\":{\"hidden\":true,\"value\":\"johnsonamp\"},\"order\":{\"hidden\":true,\"value\":\"23\"},\"qid\":{\"toolbar\":false,\"value\":\"input_49\"},\"reminderEmails\":{\"hidden\":true,\"value\":{\"schedule\":[{\"value\":\"2\",\"unit\":\"hour\"}]}},\"type\":{\"hidden\":true,\"value\":\"control_appointment\"},\"useReminderEmails\":{\"hidden\":true,\"value\":\"No\"},\"id\":{\"toolbar\":false,\"value\":\"49\"},\"qname\":{\"toolbar\":false,\"value\":\"q49_johnsonamp\"},\"cdnconfig\":{\"CDN\":\"https:\/\/cdn.jotfor.ms\/\"},\"passive\":false,\"formProperties\":{\"products\":false,\"highlightLine\":\"Enabled\",\"coupons\":false,\"useStripeCoupons\":false,\"taxes\":false,\"comparePaymentForm\":\"\",\"paymentListSettings\":false,\"newPaymentUIForNewCreatedForms\":\"Yes\",\"formBackground\":\"#fff\"},\"formID\":212695859147167,\"isPaymentForm\":false,\"isOpenedInPortal\":false,\"isCheckoutForm\":false,\"cartProducts\":[],\"isFastCheckoutShoppingApp\":false,\"translatedProductListTexts\":false,\"productListColors\":false,\"themeVersion\":\"v2\"});\n  \n    JotForm.calendarMonths = [\"January\",\"February\",\"March\",\"April\",\"May\",\"June\",\"July\",\"August\",\"September\",\"October\",\"November\",\"December\"];\n    JotForm.appointmentCalendarDays = [\"Monday\",\"Tuesday\",\"Wednesday\",\"Thursday\",\"Friday\",\"Saturday\",\"Sunday\"];\n    JotForm.calendarOther = \"Today\";\n    window.initializeAppointment({\"text\":{\"text\":\"Question\",\"value\":\"Moderna - Weehawken Location\"},\"labelAlign\":{\"text\":\"Label Align\",\"value\":\"Top\",\"dropdown\":[[\"Auto\",\"Auto\"],[\"Left\",\"Left\"],[\"Right\",\"Right\"],[\"Top\",\"Top\"]]},\"required\":{\"text\":\"Required\",\"value\":\"Yes\",\"dropdown\":[[\"No\",\"No\"],[\"Yes\",\"Yes\"]]},\"description\":{\"text\":\"Hover Text\",\"value\":\"\",\"textarea\":true},\"slotDuration\":{\"text\":\"Slot Duration\",\"value\":\"15\",\"dropdown\":[[15,\"15 min\"],[30,\"30 min\"],[45,\"45 min\"],[60,\"60 min\"],[\"custom\",\"Custom min\"]],\"hint\":\"Select how long each slot will be.\"},\"startDate\":{\"text\":\"Start Date\",\"value\":\"2022-09-11\"},\"endDate\":{\"text\":\"End Date\",\"value\":\"2022-09-30\"},\"intervals\":{\"text\":\"Intervals\",\"value\":[{\"from\":\"15:00\",\"to\":\"19:00\",\"days\":[\"Wed\"]}],\"hint\":\"The hours will be applied to the selected days and repeated.\"},\"useBlockout\":{\"text\":\"Blockout Custom Dates\",\"value\":\"No\",\"dropdown\":[[\"No\",\"No\"],[\"Yes\",\"Yes\"]],\"hint\":\"Disable certain date(s) in the calendar.\"},\"blockoutDates\":{\"text\":\"Blockout dates\",\"value\":[{\"startDate\":\"\",\"endDate\":\"\"}]},\"useLunchBreak\":{\"text\":\"Lunch Time\",\"value\":\"No\",\"dropdown\":[[\"No\",\"No\"],[\"Yes\",\"Yes\"]],\"hint\":\"Enable lunchtime in the calendar.\"},\"lunchBreak\":{\"text\":\"Lunchtime hours\",\"value\":[{\"from\":\"12:00\",\"to\":\"14:00\"}]},\"timezone\":{\"text\":\"Timezone\",\"value\":\"America\/New_York (GMT-04:00)\"},\"timeFormat\":{\"text\":\"Time Format\",\"value\":\"AM\/PM\",\"dropdown\":[[\"24 Hour\",\"24 Hour\"],[\"AM\/PM\",\"AM\/PM\"]],\"icon\":\"images\/blank.gif\",\"iconClassName\":\"toolbar-time_format_24\"},\"months\":{\"value\":[\"January\",\"February\",\"March\",\"April\",\"May\",\"June\",\"July\",\"August\",\"September\",\"October\",\"November\",\"December\"],\"hidden\":true},\"days\":{\"value\":[\"Monday\",\"Tuesday\",\"Wednesday\",\"Thursday\",\"Friday\",\"Saturday\",\"Sunday\"],\"hidden\":true},\"startWeekOn\":{\"text\":\"Start Week On\",\"value\":\"Sunday\",\"dropdown\":[[\"Monday\",\"Monday\"],[\"Sunday\",\"Sunday\"]],\"toolbar\":false},\"rollingDays\":{\"text\":\"Rolling Days\",\"value\":\"14\",\"toolbar\":false},\"prevMonthButtonText\":{\"text\":\"Previous month\",\"value\":\"\"},\"nextMonthButtonText\":{\"text\":\"Next month\",\"value\":\"\"},\"prevYearButtonText\":{\"text\":\"Previous year\",\"value\":\"\"},\"nextYearButtonText\":{\"text\":\"Next year\",\"value\":\"\"},\"prevDayButtonText\":{\"text\":\"Previous day\",\"value\":\"\"},\"nextDayButtonText\":{\"text\":\"Next day\",\"value\":\"\"},\"appointmentType\":{\"hidden\":true,\"value\":\"multiple\"},\"autoDetectTimezone\":{\"hidden\":true,\"value\":\"Yes\"},\"dateFormat\":{\"hidden\":true,\"value\":\"mm\/dd\/yyyy\"},\"hidden\":{\"hidden\":true,\"value\":\"Yes\"},\"maxAttendee\":{\"hidden\":true,\"value\":\"6\"},\"maxEvents\":{\"hidden\":true,\"value\":\"50\"},\"minScheduleNotice\":{\"hidden\":true,\"value\":\"6\"},\"name\":{\"hidden\":true,\"value\":\"moderna14\"},\"order\":{\"hidden\":true,\"value\":\"24\"},\"qid\":{\"toolbar\":false,\"value\":\"input_14\"},\"reminderEmails\":{\"hidden\":true,\"value\":{\"schedule\":[{\"value\":\"2\",\"unit\":\"hour\"}]}},\"type\":{\"hidden\":true,\"value\":\"control_appointment\"},\"useReminderEmails\":{\"hidden\":true,\"value\":\"No\"},\"id\":{\"toolbar\":false,\"value\":\"14\"},\"qname\":{\"toolbar\":false,\"value\":\"q14_moderna14\"},\"cdnconfig\":{\"CDN\":\"https:\/\/cdn.jotfor.ms\/\"},\"passive\":false,\"formProperties\":{\"products\":false,\"highlightLine\":\"Enabled\",\"coupons\":false,\"useStripeCoupons\":false,\"taxes\":false,\"comparePaymentForm\":\"\",\"paymentListSettings\":false,\"newPaymentUIForNewCreatedForms\":\"Yes\",\"formBackground\":\"#fff\"},\"formID\":212695859147167,\"isPaymentForm\":false,\"isOpenedInPortal\":false,\"isCheckoutForm\":false,\"cartProducts\":[],\"isFastCheckoutShoppingApp\":false,\"translatedProductListTexts\":false,\"productListColors\":false,\"themeVersion\":\"v2\"});\n        JotForm.alterTexts(undefined);\n\t\/*INIT-END*\/\n\t});\n\n   clearInterval(jsTime);\n }catch(e){}}, 1000);\n\n   JotForm.prepareCalculationsOnTheFly([null,{\"name\":\"weehawkenCovid19\",\"qid\":\"1\",\"text\":\"Weehawken COVID-19 Vaccine Registration Form\",\"type\":\"control_head\"},{\"name\":\"submit2\",\"qid\":\"2\",\"text\":\"Submit\",\"type\":\"control_button\"},{\"description\":\"\",\"name\":\"name\",\"qid\":\"3\",\"text\":\"Name\",\"type\":\"control_fullname\"},{\"description\":\"\",\"name\":\"email\",\"qid\":\"4\",\"subLabel\":\"example@example.com\",\"text\":\"Email\",\"type\":\"control_email\"},{\"description\":\"\",\"name\":\"address\",\"qid\":\"5\",\"text\":\"Address\",\"type\":\"control_address\"},{\"description\":\"\",\"name\":\"phoneNumber\",\"qid\":\"6\",\"text\":\"Phone Number\",\"type\":\"control_phone\"},{\"description\":\"\",\"name\":\"pfizerVaccine\",\"qid\":\"7\",\"text\":\"Pfizer Vaccine - Weehawken Location\",\"type\":\"control_appointment\"},null,{\"description\":\"\",\"name\":\"preferredVaccine\",\"qid\":\"9\",\"subLabel\":\"\",\"text\":\"Preferred Vaccine\",\"type\":\"control_dropdown\"},{\"description\":\"\",\"name\":\"dateOf\",\"qid\":\"10\",\"text\":\"Date of Birth\",\"type\":\"control_datetime\"},{\"description\":\"\",\"name\":\"race\",\"qid\":\"11\",\"subLabel\":\"\",\"text\":\"Race - CDC\\u002FFEMA Requirement \",\"type\":\"control_dropdown\"},null,{\"name\":\"allThese\",\"qid\":\"13\",\"text\":\"All these questions are CDC\\u002FFEMA & State of New Jersey Requirements \",\"type\":\"control_head\"},{\"description\":\"\",\"name\":\"moderna14\",\"qid\":\"14\",\"text\":\"Moderna - Weehawken Location\",\"type\":\"control_appointment\"},null,{\"description\":\"\",\"name\":\"ethnicity\",\"qid\":\"16\",\"subLabel\":\"\",\"text\":\"Ethnicity - CDC\\u002FFEMA Requirement\",\"type\":\"control_dropdown\"},{\"description\":\"\",\"name\":\"gender17\",\"qid\":\"17\",\"subLabel\":\"\",\"text\":\"Gender\",\"type\":\"control_dropdown\"},null,null,null,null,null,null,null,null,null,{\"description\":\"\",\"name\":\"doYou27\",\"qid\":\"27\",\"text\":\"Do you have a Medical Condition ? CDC\\u002FFEMA Requirement\",\"type\":\"control_radio\"},{\"description\":\"\",\"name\":\"birthCountry\",\"qid\":\"28\",\"subLabel\":\"\",\"text\":\"Birth Country \",\"type\":\"control_dropdown\"},{\"description\":\"\",\"name\":\"birthState\",\"qid\":\"29\",\"subLabel\":\"\",\"text\":\"Birth State\",\"type\":\"control_dropdown\"},{\"description\":\"\",\"name\":\"areYou\",\"qid\":\"30\",\"text\":\"Are you a Twin ?\",\"type\":\"control_radio\"},null,null,null,null,null,null,null,{\"name\":\"reminderModerna38\",\"qid\":\"38\",\"text\":\"Reminder Moderna is for 18+ Pfizer is 5+ Parent\\u002FGuardian must accompany all minors to all vaccinations. Birth Certificate and Parental Identification will be required. \",\"type\":\"control_head\"},null,null,{\"name\":\"pleaseSelect\",\"qid\":\"41\",\"text\":\"Please select your preferred vaccine please read carefully \",\"type\":\"control_head\"},null,{\"description\":\"\",\"name\":\"whichDose43\",\"qid\":\"43\",\"subLabel\":\"\",\"text\":\"Which Dose \",\"type\":\"control_dropdown\"},null,null,{\"description\":\"\",\"labelText\":\"\",\"name\":\"vaxflow3618833e53a6e0970613318\",\"qid\":\"46\",\"text\":\"VaxFlow3.618833e53a6e09.70613318\",\"type\":\"control_image\"},{\"name\":\"input47\",\"qid\":\"47\",\"text\":\"All adults (18 and older) are eligible for the two-dose Pfizer, two-dose Moderna or one-dose Johnson &amp; Johnson vaccines.\\nAll adolescents ages 12 through 17 are eligible for the two-dose Pfizer vaccine.\\nAll children ages 5 through 11 are eligible for the pediatric two-dose Pfizer vaccine.\\nEveryone 16 and older should get a booster shot at any vaccine location if it has been at least two months since their one-dose Johnson &amp; Johnson shot or at least six months after completing their two-dose Pfizer or Moderna vaccine series.\\nAt this time, only the Pfizer vaccine is authorized and recommended for adolescents aged 16 and 17.\\nEligible individuals may choose which vaccine they receive as a booster dose. Some people may have a preference for the vaccine type that they originally received and others may prefer to get a different booster. CDC's recommendations allow for this type of mix and match dosing for booster shots.\\nCOVID-19 vaccines are working well to prevent severe illness, hospitalization, and death, even against the widely circulating Delta variant. However, studies show that vaccination may become less effective over time, especially in preventing infection or milder illness and in people over 65 years old. Booster doses provide necessary additional protection against waning immunity. All eligible individuals are encouraged to get booster shots.\",\"type\":\"control_text\"},null,{\"description\":\"\",\"name\":\"johnsonamp\",\"qid\":\"49\",\"text\":\"Johnson & Johnson - Weehawken Location\",\"type\":\"control_appointment\"},{\"description\":\"\",\"name\":\"pfizerChildrens\",\"qid\":\"50\",\"text\":\"Pfizer Children's Vaccine- 5 to 11 Years Old\",\"type\":\"control_appointment\"}]);\n   setTimeout(function() {\nJotForm.paymentExtrasOnTheFly([null,{\"name\":\"weehawkenCovid19\",\"qid\":\"1\",\"text\":\"Weehawken COVID-19 Vaccine Registration Form\",\"type\":\"control_head\"},{\"name\":\"submit2\",\"qid\":\"2\",\"text\":\"Submit\",\"type\":\"control_button\"},{\"description\":\"\",\"name\":\"name\",\"qid\":\"3\",\"text\":\"Name\",\"type\":\"control_fullname\"},{\"description\":\"\",\"name\":\"email\",\"qid\":\"4\",\"subLabel\":\"example@example.com\",\"text\":\"Email\",\"type\":\"control_email\"},{\"description\":\"\",\"name\":\"address\",\"qid\":\"5\",\"text\":\"Address\",\"type\":\"control_address\"},{\"description\":\"\",\"name\":\"phoneNumber\",\"qid\":\"6\",\"text\":\"Phone Number\",\"type\":\"control_phone\"},{\"description\":\"\",\"name\":\"pfizerVaccine\",\"qid\":\"7\",\"text\":\"Pfizer Vaccine - Weehawken Location\",\"type\":\"control_appointment\"},null,{\"description\":\"\",\"name\":\"preferredVaccine\",\"qid\":\"9\",\"subLabel\":\"\",\"text\":\"Preferred Vaccine\",\"type\":\"control_dropdown\"},{\"description\":\"\",\"name\":\"dateOf\",\"qid\":\"10\",\"text\":\"Date of Birth\",\"type\":\"control_datetime\"},{\"description\":\"\",\"name\":\"race\",\"qid\":\"11\",\"subLabel\":\"\",\"text\":\"Race - CDC\\u002FFEMA Requirement \",\"type\":\"control_dropdown\"},null,{\"name\":\"allThese\",\"qid\":\"13\",\"text\":\"All these questions are CDC\\u002FFEMA & State of New Jersey Requirements \",\"type\":\"control_head\"},{\"description\":\"\",\"name\":\"moderna14\",\"qid\":\"14\",\"text\":\"Moderna - Weehawken Location\",\"type\":\"control_appointment\"},null,{\"description\":\"\",\"name\":\"ethnicity\",\"qid\":\"16\",\"subLabel\":\"\",\"text\":\"Ethnicity - CDC\\u002FFEMA Requirement\",\"type\":\"control_dropdown\"},{\"description\":\"\",\"name\":\"gender17\",\"qid\":\"17\",\"subLabel\":\"\",\"text\":\"Gender\",\"type\":\"control_dropdown\"},null,null,null,null,null,null,null,null,null,{\"description\":\"\",\"name\":\"doYou27\",\"qid\":\"27\",\"text\":\"Do you have a Medical Condition ? CDC\\u002FFEMA Requirement\",\"type\":\"control_radio\"},{\"description\":\"\",\"name\":\"birthCountry\",\"qid\":\"28\",\"subLabel\":\"\",\"text\":\"Birth Country \",\"type\":\"control_dropdown\"},{\"description\":\"\",\"name\":\"birthState\",\"qid\":\"29\",\"subLabel\":\"\",\"text\":\"Birth State\",\"type\":\"control_dropdown\"},{\"description\":\"\",\"name\":\"areYou\",\"qid\":\"30\",\"text\":\"Are you a Twin ?\",\"type\":\"control_radio\"},null,null,null,null,null,null,null,{\"name\":\"reminderModerna38\",\"qid\":\"38\",\"text\":\"Reminder Moderna is for 18+ Pfizer is 5+ Parent\\u002FGuardian must accompany all minors to all vaccinations. Birth Certificate and Parental Identification will be required. \",\"type\":\"control_head\"},null,null,{\"name\":\"pleaseSelect\",\"qid\":\"41\",\"text\":\"Please select your preferred vaccine please read carefully \",\"type\":\"control_head\"},null,{\"description\":\"\",\"name\":\"whichDose43\",\"qid\":\"43\",\"subLabel\":\"\",\"text\":\"Which Dose \",\"type\":\"control_dropdown\"},null,null,{\"description\":\"\",\"labelText\":\"\",\"name\":\"vaxflow3618833e53a6e0970613318\",\"qid\":\"46\",\"text\":\"VaxFlow3.618833e53a6e09.70613318\",\"type\":\"control_image\"},{\"name\":\"input47\",\"qid\":\"47\",\"text\":\"All adults (18 and older) are eligible for the two-dose Pfizer, two-dose Moderna or one-dose Johnson &amp; Johnson vaccines.\\nAll adolescents ages 12 through 17 are eligible for the two-dose Pfizer vaccine.\\nAll children ages 5 through 11 are eligible for the pediatric two-dose Pfizer vaccine.\\nEveryone 16 and older should get a booster shot at any vaccine location if it has been at least two months since their one-dose Johnson &amp; Johnson shot or at least six months after completing their two-dose Pfizer or Moderna vaccine series.\\nAt this time, only the Pfizer vaccine is authorized and recommended for adolescents aged 16 and 17.\\nEligible individuals may choose which vaccine they receive as a booster dose. Some people may have a preference for the vaccine type that they originally received and others may prefer to get a different booster. CDC's recommendations allow for this type of mix and match dosing for booster shots.\\nCOVID-19 vaccines are working well to prevent severe illness, hospitalization, and death, even against the widely circulating Delta variant. However, studies show that vaccination may become less effective over time, especially in preventing infection or milder illness and in people over 65 years old. Booster doses provide necessary additional protection against waning immunity. All eligible individuals are encouraged to get booster shots.\",\"type\":\"control_text\"},null,{\"description\":\"\",\"name\":\"johnsonamp\",\"qid\":\"49\",\"text\":\"Johnson & Johnson - Weehawken Location\",\"type\":\"control_appointment\"},{\"description\":\"\",\"name\":\"pfizerChildrens\",\"qid\":\"50\",\"text\":\"Pfizer Children's Vaccine- 5 to 11 Years Old\",\"type\":\"control_appointment\"}]);}, 20); \n<\/script>\n<\/head>\n<body>\n<form class=\"jotform-form\" action=\"https:\/\/submit.jotform.com\/submit\/212695859147167\/\" method=\"post\" name=\"form_212695859147167\" id=\"212695859147167\" accept-charset=\"utf-8\" autocomplete=\"on\">\n  <input type=\"hidden\" name=\"formID\" value=\"212695859147167\" \/>\n  <input type=\"hidden\" id=\"JWTContainer\" value=\"\" \/>\n  <input type=\"hidden\" id=\"cardinalOrderNumber\" value=\"\" \/>\n  <div role=\"main\" class=\"form-all\">\n    <style>\n      .form-all:before { background: none;}\n    <\/style>\n    <ul class=\"form-section page-section\">\n      <li id=\"cid_1\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group  header-default\">\n          <div class=\"header-text httac htvam\">\n            <h2 id=\"header_1\" class=\"form-header\" data-component=\"header\">\n              Weehawken COVID-19 Vaccine Registration Form\n            <\/h2>\n            <div id=\"subHeader_1\" class=\"form-subHeader\">\n              Everyone 5 years or older is eligible for a COVID-19 vaccine in New Jersey and encouraged to get vaccinated as soon as possible.\n            <\/div>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li id=\"cid_13\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group  header-small\">\n          <div class=\"header-text httac htvam\">\n            <h3 id=\"header_13\" class=\"form-header\" data-component=\"header\">\n              All these questions are CDC\/FEMA &amp; State of New Jersey Requirements\n            <\/h3>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_fullname\" id=\"id_3\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_3\" for=\"first_3\">\n          Name\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_3\" class=\"form-input-wide jf-required\" data-layout=\"full\">\n          <div data-wrapper-react=\"true\">\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\" data-input-type=\"first\">\n              <input type=\"text\" id=\"first_3\" name=\"q3_name[first]\" class=\"form-textbox validate[required]\" data-defaultvalue=\"\" autoComplete=\"section-input_3 given-name\" size=\"10\" value=\"\" data-component=\"first\" aria-labelledby=\"label_3 sublabel_3_first\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"first_3\" id=\"sublabel_3_first\" style=\"min-height:13px\" aria-hidden=\"false\"> First Name <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\" data-input-type=\"last\">\n              <input type=\"text\" id=\"last_3\" name=\"q3_name[last]\" class=\"form-textbox validate[required]\" data-defaultvalue=\"\" autoComplete=\"section-input_3 family-name\" size=\"15\" value=\"\" data-component=\"last\" aria-labelledby=\"label_3 sublabel_3_last\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"last_3\" id=\"sublabel_3_last\" style=\"min-height:13px\" aria-hidden=\"false\"> Last Name <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_address\" id=\"id_5\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_5\" for=\"input_5_addr_line1\">\n          Address\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_5\" class=\"form-input-wide jf-required\" data-layout=\"full\">\n          <div summary=\"\" class=\"form-address-table jsTest-addressField\">\n            <div class=\"form-address-line-wrapper jsTest-address-line-wrapperField\">\n              <span class=\"form-address-line form-address-street-line jsTest-address-lineField\">\n                <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n                  <input type=\"text\" id=\"input_5_addr_line1\" name=\"q5_address[addr_line1]\" class=\"form-textbox validate[required] form-address-line\" data-defaultvalue=\"\" autoComplete=\"section-input_5 address-line1\" value=\"\" data-component=\"address_line_1\" aria-labelledby=\"label_5 sublabel_5_addr_line1\" required=\"\" \/>\n                  <label class=\"form-sub-label\" for=\"input_5_addr_line1\" id=\"sublabel_5_addr_line1\" style=\"min-height:13px\" aria-hidden=\"false\"> Street Address <\/label>\n                <\/span>\n              <\/span>\n            <\/div>\n            <div class=\"form-address-line-wrapper jsTest-address-line-wrapperField\">\n              <span class=\"form-address-line form-address-street-line jsTest-address-lineField\">\n                <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n                  <input type=\"text\" id=\"input_5_addr_line2\" name=\"q5_address[addr_line2]\" class=\"form-textbox form-address-line\" data-defaultvalue=\"\" autoComplete=\"section-input_5 address-line2\" value=\"\" data-component=\"address_line_2\" aria-labelledby=\"label_5 sublabel_5_addr_line2\" \/>\n                  <label class=\"form-sub-label\" for=\"input_5_addr_line2\" id=\"sublabel_5_addr_line2\" style=\"min-height:13px\" aria-hidden=\"false\"> Street Address Line 2 <\/label>\n                <\/span>\n              <\/span>\n            <\/div>\n            <div class=\"form-address-line-wrapper jsTest-address-line-wrapperField\">\n              <span class=\"form-address-line form-address-city-line jsTest-address-lineField \">\n                <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n                  <input type=\"text\" id=\"input_5_city\" name=\"q5_address[city]\" class=\"form-textbox validate[required] form-address-city\" data-defaultvalue=\"\" autoComplete=\"section-input_5 address-level2\" value=\"\" data-component=\"city\" aria-labelledby=\"label_5 sublabel_5_city\" required=\"\" \/>\n                  <label class=\"form-sub-label\" for=\"input_5_city\" id=\"sublabel_5_city\" style=\"min-height:13px\" aria-hidden=\"false\"> City <\/label>\n                <\/span>\n              <\/span>\n              <span class=\"form-address-line form-address-state-line jsTest-address-lineField \">\n                <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n                  <input type=\"text\" id=\"input_5_state\" name=\"q5_address[state]\" class=\"form-textbox validate[required] form-address-state\" data-defaultvalue=\"\" autoComplete=\"section-input_5 address-level1\" value=\"\" data-component=\"state\" aria-labelledby=\"label_5 sublabel_5_state\" required=\"\" \/>\n                  <label class=\"form-sub-label\" for=\"input_5_state\" id=\"sublabel_5_state\" style=\"min-height:13px\" aria-hidden=\"false\"> State \/ Province <\/label>\n                <\/span>\n              <\/span>\n            <\/div>\n            <div class=\"form-address-line-wrapper jsTest-address-line-wrapperField\">\n              <span class=\"form-address-line form-address-zip-line jsTest-address-lineField \">\n                <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n                  <input type=\"text\" id=\"input_5_postal\" name=\"q5_address[postal]\" class=\"form-textbox validate[required] form-address-postal\" data-defaultvalue=\"\" autoComplete=\"section-input_5 postal-code\" value=\"\" data-component=\"zip\" aria-labelledby=\"label_5 sublabel_5_postal\" required=\"\" \/>\n                  <label class=\"form-sub-label\" for=\"input_5_postal\" id=\"sublabel_5_postal\" style=\"min-height:13px\" aria-hidden=\"false\"> Postal \/ Zip Code <\/label>\n                <\/span>\n              <\/span>\n            <\/div>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-1 jf-required\" data-type=\"control_email\" id=\"id_4\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_4\" for=\"input_4\">\n          Email\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_4\" class=\"form-input-wide jf-required\" data-layout=\"half\">\n          <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n            <input type=\"email\" id=\"input_4\" name=\"q4_email\" class=\"form-textbox validate[required, Email]\" data-defaultvalue=\"\" style=\"width:310px\" size=\"310\" value=\"\" data-component=\"email\" aria-labelledby=\"label_4 sublabel_input_4\" required=\"\" \/>\n            <br\/>\n            <label class=\"form-sub-label\" style=\"border:0;clip:rect(0 0 0 0);height:1px;margin:-1px;overflow:hidden;padding:0;position:absolute;width:1px;white-space:nowrap\" for=\"input_4_confirm\"> Confirmation Email <\/label>\n            <input type=\"email\" id=\"input_4_confirm\" name=\"q4_email\" class=\"form-textbox validate[required, Email, Email_Confirm]\" data-defaultvalue=\"\" style=\"margin-top:8px;width:310px\" size=\"310\" value=\"\" placeholder=\"example@example.com\" data-component=\"emailConfirmation\" \/>\n            <label class=\"form-sub-label\" for=\"input_4\" id=\"sublabel_input_4\" style=\"min-height:13px\" aria-hidden=\"false\"> example@example.com <\/label>\n          <\/span>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-2 jf-required\" data-type=\"control_phone\" id=\"id_6\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_6\" for=\"input_6_full\">\n          Phone Number\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_6\" class=\"form-input-wide jf-required\" data-layout=\"half\">\n          <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n            <input type=\"tel\" id=\"input_6_full\" name=\"q6_phoneNumber[full]\" data-type=\"mask-number\" class=\"mask-phone-number form-textbox validate[required, Fill Mask]\" data-defaultvalue=\"\" autoComplete=\"section-input_6 tel-national\" style=\"width:310px\" data-masked=\"true\" value=\"\" placeholder=\"(000) 000-0000\" data-component=\"phone\" aria-labelledby=\"label_6 sublabel_6_masked\" required=\"\" \/>\n            <label class=\"form-sub-label\" for=\"input_6_full\" id=\"sublabel_6_masked\" style=\"min-height:13px\" aria-hidden=\"false\"> Please enter a valid phone number. <\/label>\n          <\/span>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-3 jf-required\" data-type=\"control_dropdown\" id=\"id_17\">\n        <label class=\"form-label form-label-top\" id=\"label_17\" for=\"input_17\">\n          Gender\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_17\" class=\"form-input-wide jf-required\" data-layout=\"half\">\n          <select class=\"form-dropdown validate[required]\" id=\"input_17\" name=\"q17_gender17\" style=\"width:310px\" data-component=\"dropdown\" required=\"\">\n            <option value=\"\"> Please Select <\/option>\n            <option value=\"Male\"> Male <\/option>\n            <option value=\"Female\"> Female <\/option>\n            <option value=\"Non-Binary\"> Non-Binary <\/option>\n            <option value=\"Unknown\"> Unknown <\/option>\n          <\/select>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-4 jf-required\" data-type=\"control_datetime\" id=\"id_10\">\n        <label class=\"form-label form-label-top\" id=\"label_10\" for=\"lite_mode_10\">\n          Date of Birth\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_10\" class=\"form-input-wide jf-required\" data-layout=\"half\">\n          <div data-wrapper-react=\"true\">\n            <div style=\"display:none\">\n              <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n                <input type=\"tel\" class=\"form-textbox validate[required, limitDate]\" id=\"month_10\" name=\"q10_dateOf[month]\" size=\"2\" data-maxlength=\"2\" data-age=\"5\" maxLength=\"2\" value=\"\" required=\"\" autoComplete=\"section-input_10 off\" aria-labelledby=\"label_10 sublabel_10_month\" \/>\n                <span class=\"date-separate\" aria-hidden=\"true\">\n                  \u00a0-\n                <\/span>\n                <label class=\"form-sub-label\" for=\"month_10\" id=\"sublabel_10_month\" style=\"min-height:13px\" aria-hidden=\"false\"> Month <\/label>\n              <\/span>\n              <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n                <input type=\"tel\" class=\"form-textbox validate[required, limitDate]\" id=\"day_10\" name=\"q10_dateOf[day]\" size=\"2\" data-maxlength=\"2\" data-age=\"5\" maxLength=\"2\" value=\"\" required=\"\" autoComplete=\"section-input_10 off\" aria-labelledby=\"label_10 sublabel_10_day\" \/>\n                <span class=\"date-separate\" aria-hidden=\"true\">\n                  \u00a0-\n                <\/span>\n                <label class=\"form-sub-label\" for=\"day_10\" id=\"sublabel_10_day\" style=\"min-height:13px\" aria-hidden=\"false\"> Day <\/label>\n              <\/span>\n              <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n                <input type=\"tel\" class=\"form-textbox validate[required, limitDate]\" id=\"year_10\" name=\"q10_dateOf[year]\" size=\"4\" data-maxlength=\"4\" data-age=\"5\" maxLength=\"4\" value=\"\" required=\"\" autoComplete=\"section-input_10 off\" aria-labelledby=\"label_10 sublabel_10_year\" \/>\n                <label class=\"form-sub-label\" for=\"year_10\" id=\"sublabel_10_year\" style=\"min-height:13px\" aria-hidden=\"false\"> Year <\/label>\n              <\/span>\n            <\/div>\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n              <input type=\"text\" class=\"form-textbox validate[required, limitDate, validateLiteDate]\" id=\"lite_mode_10\" size=\"12\" data-maxlength=\"12\" maxLength=\"12\" data-age=\"5\" value=\"\" required=\"\" data-format=\"mmddyyyy\" data-seperator=\"-\" placeholder=\"MM-DD-YYYY\" autoComplete=\"section-input_10 off\" aria-labelledby=\"label_10 sublabel_10_litemode\" \/>\n              <img class=\" newDefaultTheme-dateIcon icon-liteMode\" alt=\"Pick a Date\" id=\"input_10_pick\" src=\"https:\/\/cdn.jotfor.ms\/images\/calendar.png\" data-component=\"datetime\" aria-hidden=\"true\" data-allow-time=\"No\" data-version=\"v2\" \/>\n              <label class=\"form-sub-label\" for=\"lite_mode_10\" id=\"sublabel_10_litemode\" style=\"min-height:13px\" aria-hidden=\"false\"> Date <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-5 jf-required\" data-type=\"control_dropdown\" id=\"id_11\">\n        <label class=\"form-label form-label-top\" id=\"label_11\" for=\"input_11\">\n          Race - CDC\/FEMA Requirement\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_11\" class=\"form-input-wide jf-required\" data-layout=\"half\">\n          <select class=\"form-dropdown validate[required]\" id=\"input_11\" name=\"q11_race\" style=\"width:310px\" data-component=\"dropdown\" required=\"\">\n            <option value=\"\"> Please Select <\/option>\n            <option value=\"American Indian OR Alaska Native\"> American Indian OR Alaska Native <\/option>\n            <option value=\"Asian\"> Asian <\/option>\n            <option value=\"Black or African-American\"> Black or African-American <\/option>\n            <option value=\"Native Hawaiian or Other Pacific Islander\"> Native Hawaiian or Other Pacific Islander <\/option>\n            <option value=\"White\"> White <\/option>\n            <option value=\"Other Race\"> Other Race <\/option>\n          <\/select>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-6 jf-required\" data-type=\"control_dropdown\" id=\"id_16\">\n        <label class=\"form-label form-label-top\" id=\"label_16\" for=\"input_16\">\n          Ethnicity - CDC\/FEMA Requirement\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_16\" class=\"form-input-wide jf-required\" data-layout=\"half\">\n          <select class=\"form-dropdown validate[required]\" id=\"input_16\" name=\"q16_ethnicity\" style=\"width:310px\" data-component=\"dropdown\" required=\"\">\n            <option value=\"\"> Please Select <\/option>\n            <option value=\"Hispanic or Latino\"> Hispanic or Latino <\/option>\n            <option value=\"Not Hispanic\"> Not Hispanic <\/option>\n          <\/select>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-7 jf-required\" data-type=\"control_radio\" id=\"id_27\">\n        <label class=\"form-label form-label-top\" id=\"label_27\" for=\"input_27\">\n          Do you have a Medical Condition ? CDC\/FEMA Requirement\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_27\" class=\"form-input-wide jf-required\" data-layout=\"full\">\n          <div class=\"form-multiple-column\" data-columncount=\"2\" role=\"group\" aria-labelledby=\"label_27\" data-component=\"radio\">\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" aria-describedby=\"label_27\" class=\"form-radio validate[required]\" id=\"input_27_0\" name=\"q27_doYou27\" value=\"Yes\" required=\"\" \/>\n              <label id=\"label_input_27_0\" for=\"input_27_0\"> Yes <\/label>\n            <\/span>\n            <span class=\"form-radio-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" aria-describedby=\"label_27\" class=\"form-radio validate[required]\" id=\"input_27_1\" name=\"q27_doYou27\" value=\"No\" required=\"\" \/>\n              <label id=\"label_input_27_1\" for=\"input_27_1\"> No <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-8 jf-required\" data-type=\"control_radio\" id=\"id_30\">\n        <label class=\"form-label form-label-top\" id=\"label_30\" for=\"input_30\">\n          Are you a Twin ?\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_30\" class=\"form-input-wide jf-required\" data-layout=\"full\">\n          <div class=\"form-single-column\" role=\"group\" aria-labelledby=\"label_30\" data-component=\"radio\">\n            <span class=\"form-radio-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" aria-describedby=\"label_30\" class=\"form-radio validate[required]\" id=\"input_30_0\" name=\"q30_areYou\" value=\"Yes\" required=\"\" \/>\n              <label id=\"label_input_30_0\" for=\"input_30_0\"> Yes <\/label>\n            <\/span>\n            <span class=\"form-radio-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" aria-describedby=\"label_30\" class=\"form-radio validate[required]\" id=\"input_30_1\" name=\"q30_areYou\" value=\"No\" required=\"\" \/>\n              <label id=\"label_input_30_1\" for=\"input_30_1\"> No <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-9 jf-required\" data-type=\"control_dropdown\" id=\"id_28\">\n        <label class=\"form-label form-label-top\" id=\"label_28\" for=\"input_28\">\n          Birth Country\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_28\" class=\"form-input-wide jf-required\" data-layout=\"half\">\n          <select class=\"form-dropdown validate[required]\" id=\"input_28\" name=\"q28_birthCountry\" style=\"width:310px\" data-component=\"dropdown\" required=\"\">\n            <option value=\"\"> Please Select <\/option>\n            <option value=\"United States\"> United States <\/option>\n            <option value=\"Afghanistan\"> Afghanistan <\/option>\n            <option value=\"Albania\"> Albania <\/option>\n            <option value=\"Algeria\"> Algeria <\/option>\n            <option value=\"American Samoa\"> American Samoa <\/option>\n            <option value=\"Andorra\"> Andorra <\/option>\n            <option value=\"Angola\"> Angola <\/option>\n            <option value=\"Anguilla\"> Anguilla <\/option>\n            <option value=\"Antigua and Barbuda\"> Antigua and Barbuda <\/option>\n            <option value=\"Argentina\"> Argentina <\/option>\n            <option value=\"Armenia\"> Armenia <\/option>\n            <option value=\"Aruba\"> Aruba <\/option>\n            <option value=\"Australia\"> Australia <\/option>\n            <option value=\"Austria\"> Austria <\/option>\n            <option value=\"Azerbaijan\"> Azerbaijan <\/option>\n            <option value=\"The Bahamas\"> The Bahamas <\/option>\n            <option value=\"Bahrain\"> Bahrain <\/option>\n            <option value=\"Bangladesh\"> Bangladesh <\/option>\n            <option value=\"Barbados\"> Barbados <\/option>\n            <option value=\"Belarus\"> Belarus <\/option>\n            <option value=\"Belgium\"> Belgium <\/option>\n            <option value=\"Belize\"> Belize <\/option>\n            <option value=\"Benin\"> Benin <\/option>\n            <option value=\"Bermuda\"> Bermuda <\/option>\n            <option value=\"Bhutan\"> Bhutan <\/option>\n            <option value=\"Bolivia\"> Bolivia <\/option>\n            <option value=\"Bosnia and Herzegovina\"> Bosnia and Herzegovina <\/option>\n            <option value=\"Botswana\"> Botswana <\/option>\n            <option value=\"Brazil\"> Brazil <\/option>\n            <option value=\"Brunei\"> Brunei <\/option>\n            <option value=\"Bulgaria\"> Bulgaria <\/option>\n            <option value=\"Burkina Faso\"> Burkina Faso <\/option>\n            <option value=\"Burundi\"> Burundi <\/option>\n            <option value=\"Cambodia\"> Cambodia <\/option>\n            <option value=\"Cameroon\"> Cameroon <\/option>\n            <option value=\"Canada\"> Canada <\/option>\n            <option value=\"Cape Verde\"> Cape Verde <\/option>\n            <option value=\"Cayman Islands\"> Cayman Islands <\/option>\n            <option value=\"Central African Republic\"> Central African Republic <\/option>\n            <option value=\"Chad\"> Chad <\/option>\n            <option value=\"Chile\"> Chile <\/option>\n            <option value=\"China\"> China <\/option>\n            <option value=\"Christmas Island\"> Christmas Island <\/option>\n            <option value=\"Cocos (Keeling) Islands\"> Cocos (Keeling) Islands <\/option>\n            <option value=\"Colombia\"> Colombia <\/option>\n            <option value=\"Comoros\"> Comoros <\/option>\n            <option value=\"Congo\"> Congo <\/option>\n            <option value=\"Cook Islands\"> Cook Islands <\/option>\n            <option value=\"Costa Rica\"> Costa Rica <\/option>\n            <option value=\"Cote d&#x27;Ivoire\"> Cote d&#x27;Ivoire <\/option>\n            <option value=\"Croatia\"> Croatia <\/option>\n            <option value=\"Cuba\"> Cuba <\/option>\n            <option value=\"Curacao\"> Curacao <\/option>\n            <option value=\"Cyprus\"> Cyprus <\/option>\n            <option value=\"Czech Republic\"> Czech Republic <\/option>\n            <option value=\"Democratic Republic of the Congo\"> Democratic Republic of the Congo <\/option>\n            <option value=\"Denmark\"> Denmark <\/option>\n            <option value=\"Djibouti\"> Djibouti <\/option>\n            <option value=\"Dominica\"> Dominica <\/option>\n            <option value=\"Dominican Republic\"> Dominican Republic <\/option>\n            <option value=\"Ecuador\"> Ecuador <\/option>\n            <option value=\"Egypt\"> Egypt <\/option>\n            <option value=\"El Salvador\"> El Salvador <\/option>\n            <option value=\"Equatorial Guinea\"> Equatorial Guinea <\/option>\n            <option value=\"Eritrea\"> Eritrea <\/option>\n            <option value=\"Estonia\"> Estonia <\/option>\n            <option value=\"Ethiopia\"> Ethiopia <\/option>\n            <option value=\"Falkland Islands\"> Falkland Islands <\/option>\n            <option value=\"Faroe Islands\"> Faroe Islands <\/option>\n            <option value=\"Fiji\"> Fiji <\/option>\n            <option value=\"Finland\"> Finland <\/option>\n            <option value=\"France\"> France <\/option>\n            <option value=\"French Polynesia\"> French Polynesia <\/option>\n            <option value=\"Gabon\"> Gabon <\/option>\n            <option value=\"The Gambia\"> The Gambia <\/option>\n            <option value=\"Georgia\"> Georgia <\/option>\n            <option value=\"Germany\"> Germany <\/option>\n            <option value=\"Ghana\"> Ghana <\/option>\n            <option value=\"Gibraltar\"> Gibraltar <\/option>\n            <option value=\"Greece\"> Greece <\/option>\n            <option value=\"Greenland\"> Greenland <\/option>\n            <option value=\"Grenada\"> Grenada <\/option>\n            <option value=\"Guadeloupe\"> Guadeloupe <\/option>\n            <option value=\"Guam\"> Guam <\/option>\n            <option value=\"Guatemala\"> Guatemala <\/option>\n            <option value=\"Guernsey\"> Guernsey <\/option>\n            <option value=\"Guinea\"> Guinea <\/option>\n            <option value=\"Guinea-Bissau\"> Guinea-Bissau <\/option>\n            <option value=\"Guyana\"> Guyana <\/option>\n            <option value=\"Haiti\"> Haiti <\/option>\n            <option value=\"Honduras\"> Honduras <\/option>\n            <option value=\"Hong Kong\"> Hong Kong <\/option>\n            <option value=\"Hungary\"> Hungary <\/option>\n            <option value=\"Iceland\"> Iceland <\/option>\n            <option value=\"India\"> India <\/option>\n            <option value=\"Indonesia\"> Indonesia <\/option>\n            <option value=\"Iran\"> Iran <\/option>\n            <option value=\"Iraq\"> Iraq <\/option>\n            <option value=\"Ireland\"> Ireland <\/option>\n            <option value=\"Israel\"> Israel <\/option>\n            <option value=\"Italy\"> Italy <\/option>\n            <option value=\"Jamaica\"> Jamaica <\/option>\n            <option value=\"Japan\"> Japan <\/option>\n            <option value=\"Jersey\"> Jersey <\/option>\n            <option value=\"Jordan\"> Jordan <\/option>\n            <option value=\"Kazakhstan\"> Kazakhstan <\/option>\n            <option value=\"Kenya\"> Kenya <\/option>\n            <option value=\"Kiribati\"> Kiribati <\/option>\n            <option value=\"North Korea\"> North Korea <\/option>\n            <option value=\"South Korea\"> South Korea <\/option>\n            <option value=\"Kosovo\"> Kosovo <\/option>\n            <option value=\"Kuwait\"> Kuwait <\/option>\n            <option value=\"Kyrgyzstan\"> Kyrgyzstan <\/option>\n            <option value=\"Laos\"> Laos <\/option>\n            <option value=\"Latvia\"> Latvia <\/option>\n            <option value=\"Lebanon\"> Lebanon <\/option>\n            <option value=\"Lesotho\"> Lesotho <\/option>\n            <option value=\"Liberia\"> Liberia <\/option>\n            <option value=\"Libya\"> Libya <\/option>\n            <option value=\"Liechtenstein\"> Liechtenstein <\/option>\n            <option value=\"Lithuania\"> Lithuania <\/option>\n            <option value=\"Luxembourg\"> Luxembourg <\/option>\n            <option value=\"Macau\"> Macau <\/option>\n            <option value=\"Macedonia\"> Macedonia <\/option>\n            <option value=\"Madagascar\"> Madagascar <\/option>\n            <option value=\"Malawi\"> Malawi <\/option>\n            <option value=\"Malaysia\"> Malaysia <\/option>\n            <option value=\"Maldives\"> Maldives <\/option>\n            <option value=\"Mali\"> Mali <\/option>\n            <option value=\"Malta\"> Malta <\/option>\n            <option value=\"Marshall Islands\"> Marshall Islands <\/option>\n            <option value=\"Martinique\"> Martinique <\/option>\n            <option value=\"Mauritania\"> Mauritania <\/option>\n            <option value=\"Mauritius\"> Mauritius <\/option>\n            <option value=\"Mayotte\"> Mayotte <\/option>\n            <option value=\"Mexico\"> Mexico <\/option>\n            <option value=\"Micronesia\"> Micronesia <\/option>\n            <option value=\"Moldova\"> Moldova <\/option>\n            <option value=\"Monaco\"> Monaco <\/option>\n            <option value=\"Mongolia\"> Mongolia <\/option>\n            <option value=\"Montenegro\"> Montenegro <\/option>\n            <option value=\"Montserrat\"> Montserrat <\/option>\n            <option value=\"Morocco\"> Morocco <\/option>\n            <option value=\"Mozambique\"> Mozambique <\/option>\n            <option value=\"Myanmar\"> Myanmar <\/option>\n            <option value=\"Nagorno-Karabakh\"> Nagorno-Karabakh <\/option>\n            <option value=\"Namibia\"> Namibia <\/option>\n            <option value=\"Nauru\"> Nauru <\/option>\n            <option value=\"Nepal\"> Nepal <\/option>\n            <option value=\"Netherlands\"> Netherlands <\/option>\n            <option value=\"Netherlands Antilles\"> Netherlands Antilles <\/option>\n            <option value=\"New Caledonia\"> New Caledonia <\/option>\n            <option value=\"New Zealand\"> New Zealand <\/option>\n            <option value=\"Nicaragua\"> Nicaragua <\/option>\n            <option value=\"Niger\"> Niger <\/option>\n            <option value=\"Nigeria\"> Nigeria <\/option>\n            <option value=\"Niue\"> Niue <\/option>\n            <option value=\"Norfolk Island\"> Norfolk Island <\/option>\n            <option value=\"Turkish Republic of Northern Cyprus\"> Turkish Republic of Northern Cyprus <\/option>\n            <option value=\"Northern Mariana\"> Northern Mariana <\/option>\n            <option value=\"Norway\"> Norway <\/option>\n            <option value=\"Oman\"> Oman <\/option>\n            <option value=\"Pakistan\"> Pakistan <\/option>\n            <option value=\"Palau\"> Palau <\/option>\n            <option value=\"Palestine\"> Palestine <\/option>\n            <option value=\"Panama\"> Panama <\/option>\n            <option value=\"Papua New Guinea\"> Papua New Guinea <\/option>\n            <option value=\"Paraguay\"> Paraguay <\/option>\n            <option value=\"Peru\"> Peru <\/option>\n            <option value=\"Philippines\"> Philippines <\/option>\n            <option value=\"Pitcairn Islands\"> Pitcairn Islands <\/option>\n            <option value=\"Poland\"> Poland <\/option>\n            <option value=\"Portugal\"> Portugal <\/option>\n            <option value=\"Puerto Rico\"> Puerto Rico <\/option>\n            <option value=\"Qatar\"> Qatar <\/option>\n            <option value=\"Republic of the Congo\"> Republic of the Congo <\/option>\n            <option value=\"Romania\"> Romania <\/option>\n            <option value=\"Russia\"> Russia <\/option>\n            <option value=\"Rwanda\"> Rwanda <\/option>\n            <option value=\"Saint Barthelemy\"> Saint Barthelemy <\/option>\n            <option value=\"Saint Helena\"> Saint Helena <\/option>\n            <option value=\"Saint Kitts and Nevis\"> Saint Kitts and Nevis <\/option>\n            <option value=\"Saint Lucia\"> Saint Lucia <\/option>\n            <option value=\"Saint Martin\"> Saint Martin <\/option>\n            <option value=\"Saint Pierre and Miquelon\"> Saint Pierre and Miquelon <\/option>\n            <option value=\"Saint Vincent and the Grenadines\"> Saint Vincent and the Grenadines <\/option>\n            <option value=\"Samoa\"> Samoa <\/option>\n            <option value=\"San Marino\"> San Marino <\/option>\n            <option value=\"Sao Tome and Principe\"> Sao Tome and Principe <\/option>\n            <option value=\"Saudi Arabia\"> Saudi Arabia <\/option>\n            <option value=\"Senegal\"> Senegal <\/option>\n            <option value=\"Serbia\"> Serbia <\/option>\n            <option value=\"Seychelles\"> Seychelles <\/option>\n            <option value=\"Sierra Leone\"> Sierra Leone <\/option>\n            <option value=\"Singapore\"> Singapore <\/option>\n            <option value=\"Slovakia\"> Slovakia <\/option>\n            <option value=\"Slovenia\"> Slovenia <\/option>\n            <option value=\"Solomon Islands\"> Solomon Islands <\/option>\n            <option value=\"Somalia\"> Somalia <\/option>\n            <option value=\"Somaliland\"> Somaliland <\/option>\n            <option value=\"South Africa\"> South Africa <\/option>\n            <option value=\"South Ossetia\"> South Ossetia <\/option>\n            <option value=\"South Sudan\"> South Sudan <\/option>\n            <option value=\"Spain\"> Spain <\/option>\n            <option value=\"Sri Lanka\"> Sri Lanka <\/option>\n            <option value=\"Sudan\"> Sudan <\/option>\n            <option value=\"Suriname\"> Suriname <\/option>\n            <option value=\"Svalbard\"> Svalbard <\/option>\n            <option value=\"eSwatini\"> eSwatini <\/option>\n            <option value=\"Sweden\"> Sweden <\/option>\n            <option value=\"Switzerland\"> Switzerland <\/option>\n            <option value=\"Syria\"> Syria <\/option>\n            <option value=\"Taiwan\"> Taiwan <\/option>\n            <option value=\"Tajikistan\"> Tajikistan <\/option>\n            <option value=\"Tanzania\"> Tanzania <\/option>\n            <option value=\"Thailand\"> Thailand <\/option>\n            <option value=\"Timor-Leste\"> Timor-Leste <\/option>\n            <option value=\"Togo\"> Togo <\/option>\n            <option value=\"Tokelau\"> Tokelau <\/option>\n            <option value=\"Tonga\"> Tonga <\/option>\n            <option value=\"Transnistria Pridnestrovie\"> Transnistria Pridnestrovie <\/option>\n            <option value=\"Trinidad and Tobago\"> Trinidad and Tobago <\/option>\n            <option value=\"Tristan da Cunha\"> Tristan da Cunha <\/option>\n            <option value=\"Tunisia\"> Tunisia <\/option>\n            <option value=\"Turkey\"> Turkey <\/option>\n            <option value=\"Turkmenistan\"> Turkmenistan <\/option>\n            <option value=\"Turks and Caicos Islands\"> Turks and Caicos Islands <\/option>\n            <option value=\"Tuvalu\"> Tuvalu <\/option>\n            <option value=\"Uganda\"> Uganda <\/option>\n            <option value=\"Ukraine\"> Ukraine <\/option>\n            <option value=\"United Arab Emirates\"> United Arab Emirates <\/option>\n            <option value=\"United Kingdom\"> United Kingdom <\/option>\n            <option value=\"Uruguay\"> Uruguay <\/option>\n            <option value=\"Uzbekistan\"> Uzbekistan <\/option>\n            <option value=\"Vanuatu\"> Vanuatu <\/option>\n            <option value=\"Vatican City\"> Vatican City <\/option>\n            <option value=\"Venezuela\"> Venezuela <\/option>\n            <option value=\"Vietnam\"> Vietnam <\/option>\n            <option value=\"British Virgin Islands\"> British Virgin Islands <\/option>\n            <option value=\"Isle of Man\"> Isle of Man <\/option>\n            <option value=\"US Virgin Islands\"> US Virgin Islands <\/option>\n            <option value=\"Wallis and Futuna\"> Wallis and Futuna <\/option>\n            <option value=\"Western Sahara\"> Western Sahara <\/option>\n            <option value=\"Yemen\"> Yemen <\/option>\n            <option value=\"Zambia\"> Zambia <\/option>\n            <option value=\"Zimbabwe\"> Zimbabwe <\/option>\n          <\/select>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-10 jf-required form-field-hidden\" style=\"display:none;\" data-type=\"control_dropdown\" id=\"id_29\">\n        <label class=\"form-label form-label-top\" id=\"label_29\" for=\"input_29\">\n          Birth State\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_29\" class=\"form-input-wide jf-required\" data-layout=\"half\">\n          <select class=\"form-dropdown validate[required]\" id=\"input_29\" name=\"q29_birthState\" style=\"width:310px\" data-component=\"dropdown\" required=\"\">\n            <option value=\"\"> Please Select <\/option>\n            <option value=\"AL\"> AL <\/option>\n            <option value=\"AK\"> AK <\/option>\n            <option value=\"AR\"> AR <\/option>\n            <option value=\"AZ\"> AZ <\/option>\n            <option value=\"CA\"> CA <\/option>\n            <option value=\"CO\"> CO <\/option>\n            <option value=\"CT\"> CT <\/option>\n            <option value=\"DC\"> DC <\/option>\n            <option value=\"DE\"> DE <\/option>\n            <option value=\"FL\"> FL <\/option>\n            <option value=\"GA\"> GA <\/option>\n            <option value=\"HI\"> HI <\/option>\n            <option value=\"ID\"> ID <\/option>\n            <option value=\"IL\"> IL <\/option>\n            <option value=\"IN\"> IN <\/option>\n            <option value=\"IA\"> IA <\/option>\n            <option value=\"KS\"> KS <\/option>\n            <option value=\"KY\"> KY <\/option>\n            <option value=\"LA\"> LA <\/option>\n            <option value=\"ME\"> ME <\/option>\n            <option value=\"MD\"> MD <\/option>\n            <option value=\"MA\"> MA <\/option>\n            <option value=\"MI\"> MI <\/option>\n            <option value=\"MN\"> MN <\/option>\n            <option value=\"MS\"> MS <\/option>\n            <option value=\"MO\"> MO <\/option>\n            <option value=\"MT\"> MT <\/option>\n            <option value=\"NE\"> NE <\/option>\n            <option value=\"NV\"> NV <\/option>\n            <option value=\"NH\"> NH <\/option>\n            <option value=\"NJ\"> NJ <\/option>\n            <option value=\"NM\"> NM <\/option>\n            <option value=\"NY\"> NY <\/option>\n            <option value=\"NC\"> NC <\/option>\n            <option value=\"ND\"> ND <\/option>\n            <option value=\"OH\"> OH <\/option>\n            <option value=\"OK\"> OK <\/option>\n            <option value=\"OR\"> OR <\/option>\n            <option value=\"PA\"> PA <\/option>\n            <option value=\"PR\"> PR <\/option>\n            <option value=\"RI\"> RI <\/option>\n            <option value=\"SC\"> SC <\/option>\n            <option value=\"SD\"> SD <\/option>\n            <option value=\"TN\"> TN <\/option>\n            <option value=\"TX\"> TX <\/option>\n            <option value=\"UT\"> UT <\/option>\n            <option value=\"VT\"> VT <\/option>\n            <option value=\"VI\"> VI <\/option>\n            <option value=\"VA\"> VA <\/option>\n            <option value=\"WA\"> WA <\/option>\n            <option value=\"WV\"> WV <\/option>\n            <option value=\"WI\"> WI <\/option>\n            <option value=\"WY\"> WY <\/option>\n          <\/select>\n        <\/div>\n      <\/li>\n      <li id=\"cid_41\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group  header-default\">\n          <div class=\"header-text httac htvam\">\n            <h2 id=\"header_41\" class=\"form-header\" data-component=\"header\">\n              Please select your preferred vaccine please read carefully\n            <\/h2>\n            <div id=\"subHeader_41\" class=\"form-subHeader\">\n              .\n            <\/div>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_text\" id=\"id_47\">\n        <div id=\"cid_47\" class=\"form-input-wide\" data-layout=\"full\">\n          <div id=\"text_47\" class=\"form-html\" data-component=\"text\" tabindex=\"0\">\n            <p style=\"text-align: justify;\">All adults (18 and older) are eligible for the two-dose Pfizer, two-dose Moderna or one-dose Johnson &amp; Johnson vaccines.<\/p>\n            <p style=\"text-align: justify;\">All adolescents ages 12 through 17 are eligible for the two-dose Pfizer vaccine.<\/p>\n            <p style=\"text-align: justify;\">All children ages 5 through 11 are eligible for the pediatric two-dose Pfizer vaccine.<\/p>\n            <p>Everyone 16 and older should get a booster shot at any vaccine location if it has been at least two months since their one-dose Johnson &amp; Johnson shot or at least six months after completing their two-dose Pfizer or Moderna vaccine series.<\/p>\n            <p>At this time, only the Pfizer vaccine is authorized and recommended for adolescents aged 16 and 17.<\/p>\n            <p>Eligible individuals may choose which vaccine they receive as a booster dose. Some people may have a preference for the vaccine type that they originally received and others may prefer to get a different booster. CDC's recommendations allow for this type of mix and match dosing for booster shots.<\/p>\n            <p>COVID-19 vaccines are working well to prevent severe illness, hospitalization, and death, even against the widely circulating Delta variant. However, studies show that vaccination may become less effective over time, especially in preventing infection or milder illness and in people over 65 years old. Booster doses provide necessary additional protection against waning immunity. All eligible individuals are encouraged to get booster shots.<\/p>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line always-hidden\" data-type=\"control_image\" id=\"id_46\">\n        <div id=\"cid_46\" class=\"form-input-wide always-hidden\" data-layout=\"full\">\n          <div style=\"text-align:center\">\n            <img alt=\"\" loading=\"lazy\" class=\"form-image\" style=\"border:0\" src=\"https:\/\/www.jotform.com\/uploads\/Giovanni_Ahmad\/form_files\/VaxFlow3.618833e53a6e09.70613318.png\" height=\"525px\" width=\"680px\" data-component=\"image\" \/>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_dropdown\" id=\"id_9\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_9\" for=\"input_9\">\n          Preferred Vaccine\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_9\" class=\"form-input-wide jf-required\" data-layout=\"half\">\n          <select class=\"form-dropdown validate[required]\" id=\"input_9\" name=\"q9_preferredVaccine\" style=\"width:310px\" data-component=\"dropdown\" required=\"\">\n            <option value=\"\"> Please Select <\/option>\n            <option value=\"Johnson &amp; Johnson Vaccine - Weehawken Location\"> Johnson &amp; Johnson Vaccine - Weehawken Location <\/option>\n            <option value=\"Moderna Vaccine - Weehawken Location\"> Moderna Vaccine - Weehawken Location <\/option>\n            <option value=\"Pfizer Vaccine - Weehawken Location\"> Pfizer Vaccine - Weehawken Location <\/option>\n            <option value=\"Pfizer Children&#x27;s Vaccine - 5 to 11 Years Old\"> Pfizer Children&#x27;s Vaccine - 5 to 11 Years Old <\/option>\n          <\/select>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_dropdown\" id=\"id_43\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_43\" for=\"input_43\">\n          Which Dose\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_43\" class=\"form-input-wide jf-required\" data-layout=\"half\">\n          <select class=\"form-dropdown validate[required]\" id=\"input_43\" name=\"q43_whichDose43\" style=\"width:310px\" data-component=\"dropdown\" required=\"\">\n            <option value=\"\"> Please Select <\/option>\n            <option value=\"First Dose\"> First Dose <\/option>\n            <option value=\"Second Dose\"> Second Dose <\/option>\n            <option value=\"1st Booster Dose \/ Third Dose\"> 1st Booster Dose \/ Third Dose <\/option>\n            <option value=\"2nd Booster Dose \/ Fourth Dose\"> 2nd Booster Dose \/ Fourth Dose <\/option>\n          <\/select>\n        <\/div>\n      <\/li>\n      <li id=\"cid_38\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group  header-default\">\n          <div class=\"header-text httac htvam\">\n            <h2 id=\"header_38\" class=\"form-header\" data-component=\"header\">\n              Reminder Moderna is for 18+ Pfizer is 5+ Parent\/Guardian must accompany all minors to all vaccinations. Birth Certificate and Parental Identification will be required.\n            <\/h2>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line always-hidden jf-required form-field-hidden\" style=\"display:none;\" data-type=\"control_appointment\" id=\"id_7\">\n        <label class=\"form-label form-label-top\" id=\"label_7\" for=\"input_7\">\n          Pfizer Vaccine - Weehawken Location\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_7\" class=\"form-input-wide always-hidden jf-required\" data-layout=\"full\">\n          <div id=\"input_7\" class=\"appointmentFieldWrapper jfQuestion-fields\">\n            <input class=\"appointmentFieldInput validate\" name=\"q7_pfizerVaccine[date]\" id=\"input_7_date\" \/>\n            <input class=\"appointmentFieldInput\" name=\"q7_pfizerVaccine[duration]\" value=\"15\" id=\"input_7_duration\" \/>\n            <input class=\"appointmentFieldInput\" name=\"q7_pfizerVaccine[timezone]\" value=\"America\/New_York (GMT-04:00)\" id=\"input_7_timezone\" \/>\n            <div class=\"appointmentField\">\n            <\/div>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line always-hidden jf-required form-field-hidden\" style=\"display:none;\" data-type=\"control_appointment\" id=\"id_50\">\n        <label class=\"form-label form-label-top\" id=\"label_50\" for=\"input_50\">\n          Pfizer Children's Vaccine- 5 to 11 Years Old\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_50\" class=\"form-input-wide always-hidden jf-required\" data-layout=\"full\">\n          <div id=\"input_50\" class=\"appointmentFieldWrapper jfQuestion-fields\">\n            <input class=\"appointmentFieldInput validate\" name=\"q50_pfizerChildrens[date]\" id=\"input_50_date\" \/>\n            <input class=\"appointmentFieldInput\" name=\"q50_pfizerChildrens[duration]\" value=\"15\" id=\"input_50_duration\" \/>\n            <input class=\"appointmentFieldInput\" name=\"q50_pfizerChildrens[timezone]\" value=\"America\/New_York (GMT-05:00)\" id=\"input_50_timezone\" \/>\n            <div class=\"appointmentField\">\n            <\/div>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line always-hidden jf-required form-field-hidden\" style=\"display:none;\" data-type=\"control_appointment\" id=\"id_49\">\n        <label class=\"form-label form-label-top\" id=\"label_49\" for=\"input_49\">\n          Johnson &amp; Johnson - Weehawken Location\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_49\" class=\"form-input-wide always-hidden jf-required\" data-layout=\"full\">\n          <div id=\"input_49\" class=\"appointmentFieldWrapper jfQuestion-fields\">\n            <input class=\"appointmentFieldInput validate\" name=\"q49_johnsonamp[date]\" id=\"input_49_date\" \/>\n            <input class=\"appointmentFieldInput\" name=\"q49_johnsonamp[duration]\" value=\"15\" id=\"input_49_duration\" \/>\n            <input class=\"appointmentFieldInput\" name=\"q49_johnsonamp[timezone]\" value=\"America\/New_York (GMT-05:00)\" id=\"input_49_timezone\" \/>\n            <div class=\"appointmentField\">\n            <\/div>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line always-hidden jf-required form-field-hidden\" style=\"display:none;\" data-type=\"control_appointment\" id=\"id_14\">\n        <label class=\"form-label form-label-top\" id=\"label_14\" for=\"input_14\">\n          Moderna - Weehawken Location\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_14\" class=\"form-input-wide always-hidden jf-required\" data-layout=\"full\">\n          <div id=\"input_14\" class=\"appointmentFieldWrapper jfQuestion-fields\">\n            <input class=\"appointmentFieldInput validate\" name=\"q14_moderna14[date]\" id=\"input_14_date\" \/>\n            <input class=\"appointmentFieldInput\" name=\"q14_moderna14[duration]\" value=\"15\" id=\"input_14_duration\" \/>\n            <input class=\"appointmentFieldInput\" name=\"q14_moderna14[timezone]\" value=\"America\/New_York (GMT-04:00)\" id=\"input_14_timezone\" \/>\n            <div class=\"appointmentField\">\n            <\/div>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_button\" id=\"id_2\">\n        <div id=\"cid_2\" class=\"form-input-wide\" data-layout=\"full\">\n          <div data-align=\"auto\" class=\"form-buttons-wrapper form-buttons-auto   jsTest-button-wrapperField\">\n            <button id=\"input_2\" type=\"submit\" class=\"form-submit-button submit-button jf-form-buttons jsTest-submitField\" data-component=\"button\" data-content=\"\">\n              Submit\n            <\/button>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li style=\"clear:both\">\n      <\/li>\n      <li style=\"display:none\">\n        Should be Empty:\n        <input type=\"text\" name=\"website\" value=\"\" \/>\n      <\/li>\n    <\/ul>\n  <\/div>\n  <script>\n  JotForm.showJotFormPowered = \"0\";\n  <\/script>\n  <script>\n  JotForm.poweredByText = \"Powered by Jotform\";\n  <\/script>\n  <input type=\"hidden\" class=\"simple_spc\" id=\"simple_spc\" name=\"simple_spc\" value=\"212695859147167\" \/>\n  <script type=\"text\/javascript\">\n  var all_spc = document.querySelectorAll(\"form[id='212695859147167'] .si\" + \"mple\" + \"_spc\");\nfor (var i = 0; i < all_spc.length; i++)\n{\n  all_spc[i].value = \"212695859147167-212695859147167\";\n}\n  <\/script>\n<\/form><\/body>\n<\/html>\n<script src=\"https:\/\/cdn.jotfor.ms\/\/js\/vendor\/smoothscroll.min.js?v=3.3.35816\"><\/script>\n<script src=\"https:\/\/cdn.jotfor.ms\/\/js\/errorNavigation.js?v=3.3.35816\"><\/script>\n","Weehawken Vaccine V3",Array);(function(){window.handleIFrameMessage=function(e){if(!e.data||!e.data.split)return;var args=e.data.split(":");if(args[2]!="212695859147167"){return;}
var iframe=document.getElementById("212695859147167");if(!iframe){return};switch(args[0]){case"scrollIntoView":if(!("nojump"in FrameBuilder.get)){iframe.scrollIntoView();}
break;case"setHeight":var height=args[1]+"px";if(window.jfDeviceType==='mobile'&&typeof $jot!=='undefined'){var parent=$jot(iframe).closest('.jt-feedback.u-responsive-lightbox');if(parent){height='100%';}}
iframe.style.height=height
break;case"setMinHeight":iframe.style.minHeight=args[1]+"px";break;case"collapseErrorPage":if(iframe.clientHeight>window.innerHeight){iframe.style.height=window.innerHeight+"px";}
break;case"reloadPage":if(iframe){location.reload();}
break;case"removeIframeOnloadAttr":iframe.removeAttribute("onload");break;case"loadScript":if(!window.isPermitted(e.origin,['jotform.com','jotform.pro'])){break;}
var src=args[1];if(args.length>3){src=args[1]+':'+args[2];}
var script=document.createElement('script');script.src=src;script.type='text/javascript';document.body.appendChild(script);break;case"exitFullscreen":if(window.document.exitFullscreen)window.document.exitFullscreen();else if(window.document.mozCancelFullScreen)window.document.mozCancelFullScreen();else if(window.document.mozCancelFullscreen)window.document.mozCancelFullScreen();else if(window.document.webkitExitFullscreen)window.document.webkitExitFullscreen();else if(window.document.msExitFullscreen)window.document.msExitFullscreen();break;case'setDeviceType':window.jfDeviceType=args[1];break;}};window.isPermitted=function(originUrl,whitelisted_domains){var url=document.createElement('a');url.href=originUrl;var hostname=url.hostname;var result=false;if(typeof hostname!=='undefined'){whitelisted_domains.forEach(function(element){if(hostname.slice((-1*element.length-1))==='.'.concat(element)||hostname===element){result=true;}});return result;}};if(window.addEventListener){window.addEventListener("message",handleIFrameMessage,false);}else if(window.attachEvent){window.attachEvent("onmessage",handleIFrameMessage);}})();